HF4347

Purpose

To ensure people who are covered by both a health plan and Minnesota Medical Assistance (MA) receive coverage for home care nursing services without being limited by quantity Caps, and to align cost-sharing with other similar health services. The bill also clarifies how these services are defined, described in policy materials, and managed by health plans (including prior authorization and use of contracted providers).

Main Provisions

• Coverage requirement: Home care nursing services, as defined in this bill, must be covered under a health plan for individuals who are concurrently enrolled in both the health plan and MA under Minnesota law.
• Cost-sharing: Any copayments, coinsurance, deductibles, or other cost-sharing for home care nursing services are allowed, but cannot be higher than the cost-sharing for other similar health plan services.
• Prior authorization and providers: Health plans may require prior authorization and may use contracted providers as allowed by existing MA rules.
• No quantity limits: Health plans may not impose any quantity or amount limits on coverage for home care nursing services.
• Policy references: Health plans must clearly reference all services that meet the definition of home care nursing services in their policy documents, including certificates, contracts, utilization policies, claims forms, and enrollee communications.
• Definition of home care nursing services: Ongoing, continuous nursing care that is medically necessary to maintain, stabilize, or restore a recipient’s health due to medical complexity or the need for sustained skilled nursing assessment, intervention, or monitoring. These services must be provided for a duration or frequency that cannot be safely or effectively met through intermittent or episodic nursing visits. Services are ordered by a physician, APRN, or physician assistant and provided by a registered nurse (RN) or licensed practical nurse (LPN) within the provider’s scope of practice.

Changes to Existing Law

• The statute governing health plan coverage for home care nursing is amended to add explicit dual-coverage protections and define the scope and administration of these services.
• The bill sets explicit safeguards on cost-sharing and prohibits quantity limitations, which are new requirements for home care nursing services under a health plan.

Definitions and Key Terms (as used in the bill)

• Home care nursing services: The defined set of ongoing, continuous nursing services meeting medical necessity for individuals with medical complexity, ordered by a physician, APRN, or PA, and delivered by RN or LPN, for a duration/frequency not safely achievable through episodic care.
• Health plan: The insurer or plan providing coverage in which the home care nursing services are to be covered.
• Medical Assistance (MA): Minnesota’s publicly funded health coverage program.
• Copayment, Coinsurance, Deductible, Cost-sharing: The various forms of patient payments that may apply to services under a health plan, limited by the rule that they cannot exceed the burden for similar services.
• Prior authorization: A process health plans may use to approve services before care is received.
• Contracted providers: Health plan–approved providers under contract with the plan.
• Policy certificate/other evidence of coverage: The formal documents that explain what the plan covers and how.

Relevant Terms home care nursing services, health plan, medical assistance (MA), concurrent coverage, copayment, coinsurance, deductible, cost-sharing, prior authorization, contracted providers, policy certificate, utilization review, claims forms, physician, advanced practice registered nurse (APRN), physician assistant (PA), registered nurse (RN), licensed practical nurse (LPN), medical necessity, medical complexity, continuous nursing, ongoing nursing, intermittent nursing, episodic nursing, quantity limitation, 62J.26, 256B.0625, 256B.0654