Minnesota Medicaid State Plan

The Minnesota Department of Human Services (DHS) provided this copy of the Minnesota Medicaid Plan at the request of the MSBA Elder Law Section.


The Plan document was posted in February, 2010 and has not been revised. Do not rely on the document's accuracy without contacting DHS for updates.(See DHS contact information.)

Attachments to Section 1: Single State Agency Organization

1.2-A Department of Human Services Organization Chart
1.2-B Health Care Administration Organization Chart
1.2-C Skilled Professional Medical Personnel
1.2-D Eligibility Determination Staff

Attachments to Section 2: Coverage and Eligibility

• Supplement 1 Reasonable Classifications of Individuals Under the Age of 21, 20, 19 and 18
• Supplement 3 Method for Determining Cost Effectiveness of Caring for Certain Disabled Children at Home

• Supplement 1 Income Eligibility Levels
• Supplement 2 Resource Levels
• Supplement 3 Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered Under Medicaid
• Supplement 4 Methods for Treatment of Income that Differ from those of the SSI Program
• Supplement 5 More Restrictive Methods of Treating Resources than those of the SSI Program
• Supplement 6 Standards for Optional State Supplementary Payments
• Supplement 7 Income Levels for 1902(f) States-Categorically Needy Who are Covered Under Requirements More Restrictive than SSI
• Supplement 8 Resource Standards for 1902(f) States-Categorically Needy
• Supplement 8a More Liberal Methods of Treating Income Under 1902(r)(2) of the Act
• Supplement 8b More Liberal Methods of Treating Resources Under 1902(r)(2) of the Act
• Supplement 8c More Liberal Resource Methods under the Long Term Care Partnership Program
• Supplement 9 Transfer of Assets
• Supplement 10 Consideration of Medicaid Qualifying Trusts-Undue Hardship
• Supplement 12 Variations from the Basic Personal Needs Allowance
• Supplement 13 Eligibility Under Section 1931 of the Act
• Supplement 15 Consideration of Blood Products Settlement Payments-Waiver
• Supplement 17 Disqualification for Long-Term Care Assistance for Individuals with Substantial Home Equity

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Attachments to Section 3: Services: General Provisions

Attachment 3.1-A Amount, Duration, & Scope of Medical & Remedial Care & Services Provided to Categorically Needy

• Item 1 Inpatient Hospital Services (not ICF/MR); includes Indian Health
• Item 2.a Outpatient Hospital Services
• Item 2.b Rural and Ambulatory Services Provided by Rural Health Clinic
• Item 2.c Federally Qualified Health Center (FQHC) and Ambulatory Services
• Item 3 Other Lab and X-Ray Services
• Item 4.a Nursing Facility (not Institute for Mental Diseases) for Individuals 21/Older
• Item 4.b Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
• Item 4.c Family Planning Services and Supplies
• Item 5.a Physicians' Services
• Item 5.b Medical & Surgical Services of Dentist
• Item 6 Medical Care or Other Remedial Care Provided by Licensed Practitioners
• Item 6.a Podiatrist Services
• Item 6.b Optometrist Services
• Item 6.c Chiropractor Services
• Item 6.d Other Practitioners' Services
• Item 6.d.A Mental Health Services
• Item 6.d.B Public Health Nursing
• Item 6.d.C Ambulatory Surgical Center (ASC)
• Item 6.d.D Certified Registered Nurse Anesthetist (CRNA)
• Item 6.d.E Nurse Practitioner Services
• Item 6.d.F Case Mgmt Services (component of receiving clozapine)
• Item 6.d.G Managed Care Organization (MCO) Services
• Item 6.d.H Clinical Nurse Specialist Services
• Item 6.d.I Medication Management Therapy Services
• Item 7 Home Health Services
• Item 7.a Intermittent or Part-time Nursing Services by Home Health Agency/Registered Nurse
• Item 7.b Home Health Aide Services by Home Health Agency
• Item 7.c Medical Supplies, Equipment and Appliances in Home
• Item 7.d Physical Therapy, Occupational Therapy, Speech Pathology and Audiology Services by Home Health/Rehab Agency
• Item 8 Private Duty Nursing Services
• Item 9 Clinic Services
• Item 10 Dental Services
• Item 11 Physical Therapy and Related Services
• Item 11.a Physical Therapy Services
• Item 11.b Occupational Therapy Services
• Item 11.c Speech, Language and Hearing Therapy Services
• Item 12 Prescribed Drugs, Dentures, Prosthetic Devices and Eyeglasses Prescribed by Physician Skilled in Diseases of Eye/by Optometrist
• Item 12.a Prescribed Drugs
• Item 12.b Dentures
• Item 12.c Prosthetic Devices
• Item 12.d Eyeglasses
• Item 13 Other Diagnostic, Screening, Preventive and Rehab Services
• Item 13.a Diagnostic Services
• Item 13.b Screening Services
• Item 13.c Preventive Services
• Item 13.d Rehab Services (Day Treatment for Mental Illness, Chemical Dependency, Physical Therapy, Occupational Therapy, Audiology, Speech-Language Pathology, Respiratory Therapy)
• Item 14 Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)

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• Item 14.a Inpatient Hospital Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 14.b Nursing Facility Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 14.c ICF/MR (Inpatient Care Facility/Mental Retardation) Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 15.a NF (Nursing Facility ) Services (other than in Institution for Mental Diseases)
• Item 15.b ICF/MR (Inpatient Care Facility/Mental Retardation) Services (other than in Institution for Mental Diseases)
• Item 16 Inpatient Psychiatric Facility Services for Individuals Under Age 22
• Item 17 Nurse Midwife Services
• Item 18 Hospice Care
• Item 19 Case Mgmt Services and Special TB-related Services
• Item 20 Extended Services to Pregnant Women
• Item 20.a Pregnancy-related and Post-Partum Services for 60 Days After Pregnancy Ends
• Item 20.b Services for Any Other Medical Condition that May Complicate Pregnancy
• Item 21 Ambulatory Prenatal Care
• Item 22 Respiratory Care Services
• Item 23 Certified Pediatric or Family Nurse Practitioner Services
• Item 24 Any Other Medical Care and Other Type of Remedial Care Specified by Secretary
• Item 24.a Transportation and Other Services
• Item 24.b Services of Nurses in Religious Nonmedical Health Care Institutions
• Item 24.c Care and Services in Religious Nonmedical Health Care Institutions
• Item 24.d Nursing Facility Services for Patients Under Age 21
• Item 24.e Emergency Hospital Services
• Item 25 Home and Community Care for Functionally Disabled Elderly Individuals
• Item 26 Personal Care Assistant Services
• Item 27 Program of All-Inclusive Care for the Elderly (PACE) Services

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Notes

• Supplementary Notes: Non-covered Services
• Supplement 1 Mental Health Targeted Case Mgmt Services
• Supplement 1a Child Welfare-Targeted Case Mgmt Services
• Supplement 1b Relocation Service Coordination (RSC) Targeted Case Mgmt Services
• Supplement 1c Vulnerable Adult/Developmentally Disabled Targeted Case Mgmt Services
• Supplement 1d Homecare Targeted Case Management
• Supplement 2 Home and Community Care For Functionally Disabled Elderly Individuals
• Supplement 3 Conditions for Medical Assistance and General Assistance Medical Care Reimbursement for Prior Authorization and Second Surgical Opinion for Inpatient Surgical Procedures (Rule 68)
• Supplement 4 Alternative Health Care Plans
• Supplement 5 Program of All-inclusive Care for the Elderly (PACE) Services

3.1-A.1 Outpatient Drugs Categorically Needy

Attachment 3.1-B Amount, Duration, & Scope of Medical & Remedial Care & Services Provided to Medically Needy

• Item 1 Inpatient Hospital Services (not ICF/MR); includes Indian Health
• Item 2.a Outpatient Hospital Services
• Item 2.b Rural and Ambulatory Services Provided by Rural Health Clinic
• Item 2.c Federally Qualified Health Center (FQHC) and Ambulatory Services
• Item 3 Other Lab and X-Ray Services
• Item 4.a Nursing Facility (not Institute for Mental Diseases) for Individuals 21/Older
• Item 4.b Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
• Item 4.c Family Planning Services & Supplies
• Item 5.a Physicians' Services
• Item 5.b Medical and Surgical Services of Dentist
• Item 6 Medical Care or Other Remedial Care Provided by Licensed Practitioners
• Item 6.a Podiatrist Services
• Item 6.b Optometrist Services
• Item 6.c Chiropractor Services
• Item 6.d Other Practitioners' Services
• Item 6.d.A Mental Health Services
• Item 6.d.B Public Health Nursing
• Item 6.d.C Ambulatory Surgical Center (ASC)
• Item 6.d.D Certified Registered Nurse Anesthetist (CRNA)
• Item 6.d.E Nurse Practitioner Services
• Item 6.d.F Case Mgmt Services (component of receiving clozapine)
• Item 6.d.G Managed Care Organization (MCO) Services
• Item 6.d.H Clinical Nurse Specialist Services
• Item 6.d.I Medication Management Therapy Services
• Item 7 Home Health Services
• Item 7.a Intermittent or Part-time Nursing Services by Home Health Agency/Registered Nurse
• Item 7.b Home Health Aide Services by Home Health Agency
• Item 7.c Medical Supplies, Equipment and Appliances in Home
• Item 7.d Physical Therapy, Occupational Therapy, Speech Pathology and Audiology Services by Home Health/Rehab Agency
• Item 8 Private Duty Nursing Services
• Item 9 Clinic Services
• Item 10 Dental Services
• Item 11 Physical Therapy and Related Services
• Item 11.a Physical Therapy Services
• Item 11.b Occupational Therapy Services
• Item 11.c Speech, Language and Hearing Therapy Services
• Item 12 Prescribed Drugs, Dentures, Prosthetic Devices and Eyeglasses Prescribed by Physician Skilled in Diseases of Eye/by Optometrist
• Item 12.a Prescribed Drugs
• Item 12.b Dentures
• Item 12.c Prosthetic Devices
• Item 12.d Eyeglasses
• Item 13 Other Diagnostic, Screening, Preventive and Rehab Services
• Item 13.a Diagnostic Services
• Item 13.b Screening Services
• Item 13.c Preventive Services
• Item 13.d Rehab Services (Day Treatment for Mental Illness, Chemical Dependency, Physical Therapy, Occupational Therapy, Audiology, Speech-Language Pathology, Respiratory Therapy)
• Item 14 Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)

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• Item 14.a Inpatient Hospital Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 14.b Nursing Facility Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 14.c ICF/MR (Inpatient Care Facility/Mental Retardation) Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 15.a NF (Nursing Facility ) Services (other than in Institution for Mental Diseases)
• Item 15.b ICF/MR (Inpatient Care Facility/Mental Retardation) Services (other than in Institution for Mental Diseases)
• Item 16 Inpatient Psychiatric Facility Services for Individuals Under Age 22
• Item 17 Nurse Midwife Services
• Item 18 Hospice Care
• Item 19 Case Mgmt Services and Special TB-related Services
• Item 20 Extended Services to Pregnant Women
• Item 20.a Pregnancy-related and Post-Partum Services for 60 Days After Pregnancy Ends
• Item 20.b Services for Any Other Medical Condition that May Complicate Pregnancy
• Item 21 Ambulatory Prenatal Care
• Item 22 Respiratory Care Services
• Item 23 Certified Pediatric or Family Nurse Practitioner Services
• Item 24 Any Other Medical Care and Other Type of Remedial Care Specified by Secretary
• Item 24.a Transportation and Other Services
• Item 24.b Services of Nurses in Religious Nonmedical Health Care Institutions
• Item 24.c Care & Services in Religious Nonmedical Health Care Institutions
• Item 24.d Nursing Facility Services for Patients Under Age 21
• Item 24.e Emergency Hospital Services
• Item 25 Home and Community Care for Functionally Disabled Elderly Individuals
• Item 26 Personal Care Assistant Services
• Item 27 Program of All-Inclusive Care for the Elderly (PACE) Services

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Notes

• Supplementary Notes: Non-covered Services
• Supplement 1 Mental Health Targeted Case Mgmt Services
• Supplement 1a Child Welfare-Targeted Case Mgmt Services
• Supplement 1b Relocation Service Coordination (RSC) Targeted Case Mgmt Services
• Supplement 1c Vulnerable Adult/Developmentally Disabled Targeted Case Mgmt Services
• Supplement 1d Homecare Targeted Case Management
• Supplement 2 Home and Community Care For Functionally Disabled Elderly Individuals
• Supplement 3 Conditions for Medical Assistance and General Assistance Medical Care Reimbursement for Prior Authorization and Second Surgical Opinion for Inpatient Surgical Procedures (Rule 68)
• Supplement 4 Alternative Health Care Plans
• Supplement 5 Program of All-inclusive Care for the Elderly (PACE) Services

3.1-B.1 Outpatient Drugs Medically Needy
3.1-C Standards and Methods of Assuring High Quality Care
3.1-D Transportation, Methods of Providing
3.1-E Standards for Coverage of Organ Transplants
3.1-F Managed Care Organization (MCO) Services
3.2-A Coordination of Title XIX with Part A and B of Title XVIII

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Attachments to Section 4: General Program Administration

• Agreement 1 Agreement with Title V Grantees—Maternal and Child Health Services
• Agreement 2 Agreement with Department of Health for Certification and Inspections of ICFs and NFs
• Agreement 3 Agreement with Department of Health for Program Development, Training, and Evaluation of Child and Teen Checkup Services
• Agreement 4 Agreement between Health Care Programs and Office of Child Support Enforcement
• Agreement 5 Interagency Agreement with Department of Jobs and Training

4.18-A Charges Imposed on Categorically Needy
4.18-C Charges Imposed on Medically Needy
4.18-D Premiums Imposed on Low-Income Pregnant Women and Infants
4.18-E Optional Sliding Scale Premiums Imposed on Qualified Disabled and Working Individuals

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4.19-A Methods and Standards for Determining Payment Rates for Inpatient Hospital Services

• Part 1 Methods and Standards for Determining Payment Rates for Inpatient Hospital Services Provided by Non-State Owned Facilities
• Part 2 Methods and Standards for Determining Payment Rates for Inpatient Hospital Services Provided in Regional Treatment Center (RTC) Programs for Persons with Mental Illness [RTC/MI]
• Part 3 Methods and Standards for Determining Payment Rates for Inpatient Hospital Services Provided in the State-owned Minnesota Neurorehabilitation Hospital [RTC/MNH]
• Part 4 Methods and Standards for Determining Payment Rates for Inpatient Hospital Services Provided in Psychiatric Hospitals with Fewer than 17 Beds
• Supplement 1 GAMC Inpatient Hospital
• Supplement 2 Cost Determination Protocol for Certifying Public Expenditures at County-Owned Hospitals

4.19-B Methods and Standards for Establishing Payment Rates-Other Types of Care

• Item 1 Inpatient Hospital Services (not ICF/MR); includes Indian Health
• Item 2.a Outpatient Hospital Services
• Item 2.b Rural and Ambulatory Services Provided by Rural Health Clinic
• Item 2.c Federally Qualified Health Center (FQHC) and Ambulatory Services
• Item 3 Other Lab and X-Ray Services
• Item 4.a Nursing Facility (not Institute for Mental Diseases) for Individuals 21/Older
• Item 4.b Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
• Item 4.c Family Planning Services and Supplies
• Item 5.a Physicians' Services
• Item 5.b Medical and Surgical Services of Dentist
• Item 6 Medical Care or Other Remedial Care Provided by Licensed Practitioners
• Item 6.a Podiatrist Services
• Item 6.b Optometrist Services
• Item 6.c Chiropractor Services
• Item 6.d Other Practitioners' Services
• Item 6.d.A Mental Health Services
• Item 6.d.B Public Health Nursing
• Item 6.d.C Ambulatory Surgical Center (ASC)
• Item 6.d.D Certified Registered Nurse Anesthetist (CRNA)
• Item 6.d.E Nurse Practitioner Services
• Item 6.d.F Case Mgmt Services (component of receiving clozapine)
• Item 6.d.G Managed Care Organization (MCO) Services
• Item 6.d.H Clinical Nurse Specialist Services
• Item 6.d.I Medication Management Therapy Services
• Item 7 Home Health Services
• Item 7.a Intermittent or Part-time Nursing Services by Home Health Agency/Registered Nurse
• Item 7.b Home Health Aide Services by Home Health Agency
• Item 7.c Medical Supplies, Equipment and Appliances in Home
• Item 7.d Physical Therapy, Occupational Therapy, Speech Pathology and Audiology Services by Home Health/Rehab Agency
• Item 8 Private Duty Nursing Services
• Item 9 Clinic Services
• Item 10 Dental Services
• Item 11 Physical Therapy and Related Services
• Item 11.a Physical Therapy Services
• Item 11.b Occupational Therapy Services
• Item 11.c Speech, Language and Hearing Therapy Services
• Item 12 Prescribed Drugs, Dentures, Prosthetic Devices and Eyeglasses Prescribed by Physician Skilled in Diseases of Eye/by Optometrist
• Item 12.a Prescribed Drugs
• Item 12.b Dentures
• Item 12.c Prosthetic Devices
• Item 12.d Eyeglasses
• Item 13 Other Diagnostic, Screening, Preventive and Rehab Services
• Item 13.a Diagnostic Services
• Item 13.b Screening Services
• Item 13.c Preventive Services
• Item 13.d Rehab Services (Day Treatment for Mental Illness, Chemical Dependency, Physical Therapy, Occupational Therapy, Audiology, Speech-Language Pathology, Respiratory Therapy)
• Item 14 Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)

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• Item 14.a Inpatient Hospital Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 14.b Nursing Facility Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 14.c ICF/MR (Inpatient Care Facility/Mental Retardation) Services for Individuals Age 65/Older in Institution for Mental Diseases (IMD)
• Item 15.a NF (Nursing Facility ) Services (other than in Institution for Mental Diseases)
• Item 15.b ICF/MR (Inpatient Care Facility/Mental Retardation) Services (other than in Institution for Mental Diseases)
• Item 16 Inpatient Psychiatric Facility Services for Individuals Under Age 22
• Item 17 Nurse Midwife Services
• Item 18 Hospice Care
• Item 19 Case Mgmt Services and Special TB-related Services
• Item 19.a Mental Health Targeted Case Mgmt Services: Supplement 1
• Item 19.b Child Welfare-Targeted Case Mgmt Services: Supplement 1a
• Item 19.c Relocation Service Coordination Services (RSC): Supplement 1b
• Item 19.d Vulnerable Adult/Developmentally Disabled Targeted Case Mgmt Services: Supplement 1c
• Item 19.e Home Care Targeted Case Mgmt Services: Supplement 1d
• Item 20 Extended Services to Pregnant Women
• Item 20.a Pregnancy-related and Post-Partum Services for 60 Days After Pregnancy Ends
• Item 20.b Services for Any Other Medical Condition that May Complicate Pregnancy
• Item 21 Ambulatory Prenatal Care
• Item 22 Respiratory Care Services
• Item 23 Certified Pediatric or Family Nurse Practitioner Services
• Item 24 Any Other Medical Care and Other Type of Remedial Care Specified by Secretary
• Item 24.a Transportation and Other Services
• Item 24.b Services of Nurses in Religious Nonmedical Health Care Institutions
• Item 24.c Care and Services in Religious Nonmedical Health Care Institutions
• Item 24.d Nursing Facility Services for Patients Under Age 21
• Item 24.e Emergency Hospital Services
• Item 25 Home and Community Care for Functionally Disabled Elderly Individuals
• Item 26 Personal Care Assistant Services
• Item 27 Program of All-Inclusive Care for the Elderly (PACE) Services
• Supplement 1 Payment of Medicare Part A and Part B Deductible/Coinsurance
• Supplement 2 Section 1926: Assuring Adequate Payment Levels for Obstetric and Pediatric Services

4.19-C Payment for Reserved Bed Days and Admission Fees

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4.19-D Methods and Standards for Determining Payment Rates for Long-term Care Services

• Part 1 Methods and Standards for Determining Payment Rates for Services Provided by Non-State Owned NFs
• Part 2 Methods and Standards for Determining Payment Rates for State-Owned NFs
• Part 3 Methods and Standards for Determining Payment Rates for NF Services Provided by a Tribe or Tribal Organization (NF Owned or Operated by Tribe/Tribal Organization)
• Part 4 Methods and Standards for Determining Payment Rates for ICF/MR Services Provided by Non-State Owned ICFs/MR
• Part 5 Methods and Standards for Determining Payment Rates for ICF/MR Services Provided by State-Owned ICFs/MR
• Supplement 1 Rates to NFs Take into Account the Costs of Nursing Facilities' Compliance with the Requirements of &1919(b) [Other than Paragraph (3)(F), (c) and (d) ] [OBRA '87]

4.19-E Timely Claims Payment-Definition of Claim

4.22-A Requirements for Third Party Liability-Identifying Liable Resources

• Supplement 1 Letter from Department of Public Safety Regarding Feasibility of Matching Recipients Against Motor Vehicle Accident Records
• Supplement 2 Department's Combined Manual: Recording Income and Eligibility Verification System Resolution Findings
• Supplement 3 Department's Combined Manual: Cooperation in Obtaining Tort Liability Payments

4.22-B Requirements for Third Party Liability-Payment of Claims
4.22-C State Methods on Cost Effectiveness of Employer-Based Group Health Plans

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4.35-A Criteria for the Application of Specified Remedies for NFs
4.35-B Specified Remedies for NFs (Termination of Provider Agreement)
4.35-C Specified Remedies for NFs (Temporary Management)
4.35-D Specified Remedies for NFs (Denial of Payment for New Admissions)
4.35-E Specified Remedies for NFs (Civil Money Penalty)
4.35-F Specified Remedies for NFs (State Monitoring)
4.35-G Specified Remedies for NFs (Transfer of Residents with Closure of NF)
4.35-H Additional Specified Remedies for NFs

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4.38 Nurse Aide Training and Competency Evaluation Programs; Nurse Aide Registry
4.38-A Collection of Additional Registry Information

4.40-A Survey & Certification Education Program
4.40-B Survey and Certification: Process for Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property
4.40-C Survey and Certification: Procedures for Scheduling and Conduct of Standard Surveys
4.40-D Survey and Certification: Programs to Measure and Reduce Inconsistency
4.40-E Survey and Certification: Process for Investigations of Complaints and Monitoring

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Attachments to Section 7: General Provisions

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                    (Link to Medicaid State Plan Sections)