Purpose

• Establish and clarify health plan coverage for home care nursing services, including how these services are defined, when they are covered, and how cost-sharing and documentation should work. The bill aims to ensure dual-eligible individuals (those enrolled in both a health plan and medical assistance) receive coverage for ongoing home care nursing without being subjected to unnecessary limits, while preserving existing authorization and provider arrangements.

Main Provisions

• Coverage for dual-eligible individuals
  • Home care nursing services (as defined later) must be covered under a health plan for persons who are concurrently covered by the health plan and enrolled in medical assistance (MA) under chapter 256B, with a specified exception related to 256B.0654 subdivision 4.
• Cost-sharing
  • A period of home care nursing services may be subject to copayment, coinsurance, deductible, or other enrollee cost-sharing requirements that apply under the health plan.
  • Cost-sharing must not place a greater financial burden on the insured than that applied to other similar services.
  • Plans may require prior authorization for these services as allowed by current law (256B.0625 subdivision 7) and may use contracted providers.
• No quantity limits
  • Health plans may not impose any quantity limitation on the coverage of home care nursing services under this section.
• Plan documents and references
  • Plans must reference all services that meet the definition of home care nursing services in their policy certificate, contract, or evidence of coverage, and related documents (utilization review policies, claims forms, instructions, communications to enrollees and providers).
• Definition of home care nursing services
  • Ongoing, individual, and continuous nursing services that are:
  • Ordered by a physician, advanced practice registered nurse (APRN), or physician assistant (PA).
  • Provided by a registered nurse (RN) or licensed practical nurse (LPN) within the provider’s scope of practice.
  • Medically necessary to maintain, stabilize, or restore the recipient’s health due to medical complexity or the need for sustained skilled nursing assessment, intervention, or monitoring.
  • Required for a duration or frequency that cannot be safely or effectively met through intermittent, episodic, or visit-based nursing services.
• Relationship to other statutes
  • The section references and applies alongside existing sections (including prior authorization and provider contracting) but does not change the allowed use of those processes.

Significant Changes to Existing Law

• Prohibits quantity limits on home care nursing coverage, reinforcing access for dual-eligible individuals.
• Expands and clarifies the definition and scope of “home care nursing services” for health plan coverage.
• Requires health plans to align policy documents and communications with the defined services, ensuring consistency across certificates, contracts, and related materials.
• Maintains existing authorization and contract provisions, while allowing prior authorization processes as applicable.
• Links coverage to the broader framework for MA and health plan coordination, including references in utilization review and claims processes.

Administrative and Legal Context

• Amends Minnesota Statutes 2024 section 62Q.545 to implement these changes.
• Includes explicit references to not applying quantity limits under 62J.26 for this coverage and to refer to all defined services in relevant plan documents.

Relevant Terms - home care nursing services - health plan - medical assistance (MA) - dual eligible (concurrently covered by health plan and MA) - copayment - coinsurance - deductible - cost-sharing - prior authorization - contracted providers - utilization review - claims forms - policy certificate - evidence of coverage - enrollees - physician - advanced practice registered nurse (APRN) - physician assistant (PA) - registered nurse (RN) - licensed practical nurse (LPN) - medical necessity - ongoing continuous nursing services - medical complexity - sustained skilled nursing assessment - intermittent/episodic/visit-based nursing services - 256B.0625 subdivision 7 - 256B.0654 subdivision 4 - 62J.26 - 62Q.545 (amended section)