Minnesota Law
Minnesota Health Law
- Health Law
Health Law
Access to the Health Care System
Paying for Health Care
The most important health care issue for individuals and their health care providers is often paying for health care. The three primary government-sponsored health care programs are Medicaid, Medicare, and MinnesotaCare. Minnesota's Department of Human Services processes payments to health care provides under these plans. In most cases, medical professionals have a right to payment within 30 days.
Medicaid
Medicaid should not be confused with Medicare. Despite their similar names, the two programs are substantially different. Medicare, described below, is a program funded and administered entirely by the federal government (Social Security Administration) to provide health care to elderly and disabled persons. Medicare coverage is uniform throughout the country. Medicaid is a cooperative program partly funded by the federal government, partly by the individual states, and mostly run by the states to provide health care to indigent persons. Each state has wide latitude in deciding how Medicaid operates within the state. In Minnesota, Medicaid provides a wider range of medical goods and services than in some other states.The federal government's role in Medicaid is quite limited. It pays a percentage of the cost of each state's health care program for indigents and ensures that every state's program complies with various federal requirements. The amount of money a state receives from the federal government is called the Federal Financial Participation (FFP). Each state's FFP is determined by a formula based on the state's per capita income and the amount of medical services the state chooses to provide to its needy persons.
For an individual to receive Medicaid, the county applies a complex formula that considers the applicant's unique situation. The individual applicant must have few assets and very low income. A person generally cannot have more than $3000 in assets or more than $420 income per month. There are several assets the formula does not count, including:
- Homestead (of any value)
- Automobile under $4500 in value, if necessary for employment, receiving health care, modified for a handicapped person, or essential for performing daily tasks
- Burial funds
- Household goods and personal effects (of any value)
- Capital and operating assets of a business necessary to earn an income
Anyone whose income is above Medicaid limits might still receive Medicaid with a spend-down provision. The spend-down is equal to the amount a person's income exceeds Medicaid limits. Medicaid occasionally agrees to cover the amount that a person's medical bills exceed a patient's spend-down.
Restructuring assets to qualify for Medicaid can be an especially attractive option for senior citizens, even if they already qualify for Medicare. Medicaid coverage is better for persons living in nursing homes because Medicaid pays for a wider variety of nursing care services and for a longer period of time than does Medicare.
Medicare
Medicare is a federal program administered entirely by the Social Security Administration and is designed to cover some basic medical and health care costs of eligible individuals over age 65 and some disabled individuals under age 65 regardless of financial need. Medicare has become an enormous federal program, providing billions of dollars in coverage every year.
Parts A and B
Medicare has two primary divisions, called Part A and Part B. Medicare Part A, commonly known as Hospital Insurance, covers medically necessary hospital and related health care. Included in Part A are costs for such expenses as inpatient hospital care necessitated by acute illness, skilled nursing home care, certified hospice care for the terminally ill, inpatient psychiatric care, and care in the home by a certified home health care provider.Medicare Part B, commonly known as Supplemental Medical Insurance, is a voluntary health insurance program designed to cover some of the costs not covered by Medicare Part A, such as outpatient hospital services, outpatient physical therapy, speech pathology services, necessary ambulance service, and medical equipment. Unlike Part A, which is paid for out of Social Security taxes and is free to anyone qualifying for it, Part B is an optional program that carries small monthly premiums.
The federal government contracts with private insurance companies to handle routine claims processing, payment, and other functions under Parts A and B. Private insurance companies contracted under Part A are called fiscal intermediaries. The fiscal intermediary for almost all of Minnesota is Blue Cross/Blue Shield of St. Paul. Private insurance companies contracted under Part B are called carriers. The Travelers of Bloomington is the carrier for the counties around the Twin Cities metropolitan area and Rochester. Blue Cross/Blue Shield is the carrier for the rest of Minnesota. The Travelers Insurance Company of Salt Lake City is the carrier for Railroad Retirement beneficiaries in Minnesota.
Anyone eligible to receive Retirement and Survivor's Insurance (RSI) or Railroad Retirement benefits is eligible to receive Medicare Part A coverage, although the person need not actually be receiving financial benefits through either of these two programs in order to receive Medicare benefits. Anyone age 65 or older not eligible for RSI or Railroad benefits can still receive Medicare Part A coverage by paying a monthly premium. Medicare Part B coverage is automatically available to anyone who qualifies for Medicare Part A benefits. In fact, all applicants for Medicare Part A benefits are automatically enrolled in Medicare Part B unless they opt out of Part B coverage.
Costs not Covered by Medicare
Medicare was never intended to provide comprehensive coverage for all medical needs of America's elderly population, but rather was intended to supplement private resources. Many health services are not covered by Medicare. For example, Medicare does not pay for:- Custodial care, such as help with bathing, walking, or exercising, that could reasonably be given by someone without medical training and is generally intended to help the patient with his or her daily living needs
- Dentures or routine dental care
- Eyeglasses, hearing aids, and examinations to prescribe or fit them
- Nursing home care (except skilled nursing care)
- Prescription drugs
- Routine physical checkups and related tests
Insurance Issues Related to Medicare
Many seniors look for some form of private insurance to supplement Medicare coverage. Some seniors are able to get continuation or conversion coverage from group policies they had at their workplace. Under these plans, seniors continue to be covered by the policies that covered them while they were working. Another popular option for seniors is to join a Health Maintenance Organization (HMO). HMO coverage is similar to continuation or conversion coverage, but many HMO's have more complicated rules for persons who are covered by Medicare, so it pays to learn about a particular HMO's policies regarding Medicare benefits before signing up.In addition, there are private insurance policies for seniors intended to cover gaps in Medicare coverage, such as deductibles, co-payments, or procedures not covered by Medicare. These policies are commonly referred to as Medigap policies. Medigap policies have been a source of much confusion and outright fraud in Minnesota. As a result, the state legislature has created a complex scheme to regulate them. The two types of Medigap policies are basic policies and extended basic policies. The State of Minnesota requires that basic Medigap coverage offered in the state include coverage for several preventative health care procedures and that extended Medigap coverage cover everything covered by basic Medigap coverage plus 100 percent of the cost of several routine cancer screening procedures, immunizations, and many more preventative tests and measures. In Minnesota, most dread disease policies -- policies designed to cover particular types of illnesses, such as cancer or heart disease -- are illegal to sell to Medicare beneficiaries. For certain indigent elderly, Medicaid is available, and therefore private insurance is financially inadvisable.
In addition, seniors may obtain prescription drugs through MinnesotaCare (discussed below) in which drug companies may voluntarily participate.
MinnesotaCare
In response to the growing number of Minnesotans unable to afford private health insurance, the Minnesota legislature created a subsidized health insurance program known as MinnesotaCare. The program is administered by the Minnesota Department of Human Services and is open to permanent Minnesota residents who are not eligible to receive Medicaid (Medical Assistance, or MA, discussed above) and who are also unable to get employer-paid health insurance and are not covered by any other health insurance plan.MinnesotaCare works like many private health insurance plans. Eligible applicants pay monthly premiums based on family size and income. In return, they receive a variety of health care services, equipment, supplies, and prescriptions from private or public providers. Many of these items have co-payments associated with them.
MinnesotaCare's eligibility requirements are complex. When originally begun, the program covered only children, parents, and dependents. As funding increased, MinnesotaCare's coverage umbrellas slowly expanded to include single adults and married couples without children whose income is no more than 135 percent above poverty level. Many persons originally ineligible to enroll have become eligible.
Access to Facilities
Hospitals may not legally refuse to treat a patient if the patient has health care insurance, but it can happen either because of prejudices or a hospital's concern about being reimbursed through Medicare or Medicaid. Several federal and state laws exist to guarantee a patient's access to health care. The Internal Revenue Service requires hospitals to admit all paying members of their communities in order to enjoy tax exempt status. The Hill-Burton Act, which provides construction grants to many hospital projects, requires hospitals receiving grants under its programs to admit all paying patients. Both Medicare and Medicaid require all hospitals participating in these programs to care for all covered patients.
Most of these laws guaranteeing access to health care facilities are rarely ever needed because hospitals are eager to admit paying patients. The AIDS epidemic has made accessibility an issue in some recent cases because some hospitals are concerned with the potentially enormous costs of fighting the disease, worried about spreading the disease, or because some decision makers object to the lifestyles of some AIDS sufferers. Laws governing the medical industry clearly forbid health care providers from using personal bias to decide whom to treat.
Access to Medical Records
In Minnesota, a health care institution must provide a patient with the originals or copies of medical or psychological records kept on file. The patient may be required to pay reasonable copying charges. The health care provider can withhold the records only if he or she believes release would be detrimental to the patient's physical or mental well-being or could cause the patient to inflict self harm or to harm another person.
Patient Control over Health Care Decisions
Right to Consent to Care
In general, a doctor cannot diagnose or treat a patient without first obtaining that person's informed consent. A doctor need not obtain a client's consent to treat mental illness, mental retardation, or chemical dependency. However, failure to obtain informed consent for any other kind of treatment can subject the doctor to charges of battery, invasion of privacy, or malpractice. If the person cannot consent for himself or herself, a guardian, conservator, or close relative can give permission to treat a patient. In an emergency, the head of a health care facility can give consent to treatment for a patient if the patient's close relatives cannot be reached. A patient's consent to treatment will be implied if the patient is unable to give consent and an emergency exists or if the patient can give consent but there is not sufficient time to properly inform the patient of all risks and alternatives.
Minors generally need to have the approval of a parent or guardian to undergo a medical or surgical procedure. Exceptions to this rule are emergencies, certain reproductive matters, testing and treatment for certain sexually-transmitted diseases, and emancipated minors. In Minnesota, a minor is considered emancipated and able to consent to medical treatment if he or she is living apart from guardians and is managing his or her personal finances.
Most doctors are smart enough to know that they should not treat a patient without any permission, so disputes in this area rarely center on whether a doctor had permission. More often, disputes turn on whether the doctor disclosed sufficient information for the patient's consent to be informed or whether the doctor went beyond the consented actions.
To give informed consent in Minnesota a patient must be given information about:
- Diagnosis
- Nature and purpose of proposed treatment
- Risks and consequences of proposed treatment
- Likelihood of success
- Alternative treatments and likely prognosis if not treated
In addition, a patient must be informed as to whether his or her treatment is experimental. Experimental research cannot be performed on a patient without the patient's consent. The consent or refusal to participate in experimental research must be recorded in the patient's permanent record.
Right to Refuse Treatment
Minnesota statutes also give patients the right to refuse treatment, medication, or dietary restrictions. Patients who refuse recommended treatments must be informed of the likely medical and psychological results of their refusal, and documentation must be placed in their record.
Anatomical Gifts
Many people want to donate their bodies to science when they die. Donated human organs can be transplanted into other people, giving the recipient a chance at a longer or more productive life. A wide variety of institutions also need bodies and organs for scientific, medical, and educational purposes. Unfortunately, many potential transplant recipients and many scientific and educational institutions are unable to secure sufficient donations because too few people are willing to donate or because potential donors do not know how to make their wishes known. To solve this problem, the state of Minnesota adopted the Uniform Anatomical Gift Act to govern the donation of bodies and body parts for transplant, medical, and scientific purposes.
Under this law, a person of sound mind, who is at least 18 years of age, may donate all or part of his or her own body. There are several ways for a donor to record his or her wish to make a donation. The donor may make the donation a provision in a will. If part of a will, the provision becomes effective immediately upon death, unlike other provisions of the will which need to go through probate before they become effective. However, a will is not the best place for a donation provision because its terms may not be known immediately upon death. If the terms of a will are not read for several days after the donor dies, it may be too late to make an effective donation. A more common form of recording one's wish to make a donation is through use of a donor card often carried in a wallet. Drivers in Minnesota can also indicate their wish to be a donor on their driver's license. In addition, one can make a written document of donation which must be signed by the donor and witnessed by at least two other people. A donation can also be made orally. Oral donations are effective if witnessed by at least two other people. A dying patient can communicate his or her wish to make a donation to an attending physician who can act as one of the required witnesses. However, the attending physician must not be the physician who removes or transplants the organ. An intent to make a gift can be revoked orally or in writing.
If there is no donation information in a client's file, doctors and hospitals in Minnesota are required, at or near the time of death, to ask the patient or his or her family about making a donation. Doctors and hospital administrators are required to use reasonable discretion and sensitivity and are not required to make a request if they feel that a body or part is not suitable for current needs.
If a dying person is unable to communicate and has not made his or her donation wishes known, a family member or guardian can make a gift of all or part of that person's body, with certain limitations.
The law forbids the sale of body parts. The recipient cannot pay for the anatomical gift but can and does pay for the cost of transportation and transplant. Only the following are allowed to receive bodies or body parts: hospitals, surgeons, physicians, educational institutions involved in medical or dental research, a storage facility for any of these persons or institutions, or any specified individual who needs the organ personally for therapy or transplantation.
Patient Rights Inside the Health Care System
Patient Bill of Rights
Patients and residents of health care facilities must be informed of their rights as patients and be given a written copy of the following rights:
- Right to know the identity of all physicians treating them and all outside health care providers
- Right to receive all appropriate health care
- Right to receive complete and current information regarding their diagnosis, treatment, alternative treatments, and risks
- Right to participate in planning their health care
- Right to refuse care (unless not competent)
- Right to privacy regarding their health care
- Right to be free from isolation and restraints unless other less restrictive measures are ineffective or not feasible
Information about Health Care Providers
Patients have the right to access some information about health care providers. Medical professionals must be licensed, and are held to certain standards of conduct. If they fail to live up to these standards, they may face punishment. Doctors who are the subject of malpractice awards or settlements must be reported to Minnesota's Board of Medical Malpractice. The Board has the authority to suspend a doctor's license for failure to pay student loans, conviction of a felony reasonably related to the medical practice, or conviction of a felony-level criminal sexual offense, for example.
Confidentiality
There are two principal forms of protection for patients worried about the confidentiality of their medical records or information they provide to their health care providers. Minnesota Rules of Evidence prohibit the introduction in court of confidential communications between a patient and a health care provider. The public policy behind this rule is the promotion of full and complete communication between doctors and their patients. Minnesota also recognizes a civil legal action for patients whose doctors release patient records without patient authorization. Under Minnesota law, a health care provider must have the patient's consent to release records to a third person. This general law does not prevent a doctor from releasing records to another doctor in an emergency for the purpose of treating the patient. Neither does it prevent the release of records to the Minnesota Department of Health.
Both of these protections will yield if they conflict with other public policies. For example, a doctor who is told by a patient that the patient plans to kill a particular person has a legal obligation to warn that person. Also, doctors have an obligation to report to the police anyone who comes for treatment of a suspicious wound, such as a stab or gunshot wound.
The AIDS epidemic has tested the boundaries of patients' rights to confidentiality. All health care providers who know that a person has HIV have a legal obligation to warn anyone with whom the carrier is intimate. The State of Minnesota requires that a diagnosis of HIV-positive status be reported to the State Department of Health. A person who is HIV-positive has an obligation to warn potential partners and to practice safe sex. Lying, misrepresenting, or failing to reveal one's HIV positive status could leave a person open to charges of fraud, misrepresentation, battery, and civil lawsuits.
Employee Health Care
Health care costs are rising and many businesses are finding it impossible to continue to give their employees the same level of benefits they once had. At the same time, individual health policies have become prohibitively expensive. As a result, more than 34 million Americans remain uninsured and the cost of health care has become one of the major reasons for strikes and other labor disputes. These are two of the primary factors creating increasing political and social pressure for health care reform and which have moved politicians to begin the difficult process of reshaping the way medical care is purchased and delivered in this country.
How these reforms progress and the shape they eventually assume will have a tremendous effect on businesses and their relationships with their employees and insurers. Many employers, whether large or small, will need to seek an attorney's help to keep track of the many changes taking place.
State Reforms
The 1993 and 1994 Legislatures modified the 1992 health care proposals with equally sweeping reforms that encourage physicians, clinics, hospitals and insurers to organize networks of health care providers into associations called integrated service networks (ISNs). Only nonprofit corporations will be allowed to form ISNs, and they must provide a full array of 24-hour health services and participate in the General Assistance, Medicaid and MinnesotaCare programs. The Minnesota Department of Health will oversee the ISNs.
Resources
Bennett J. Yankowitz and Richard A. Feinstein, Health Care Law 1993 (Practicing Law Institute, New York, NY).
Clare C. Obade, Patient Care Decision-Making: A Legal Guide for Providers (Clark Boardman Callaghan, Deerfield, IL, 1994).
Michael G. MacDonald et al., Health Care Law: A Practical Guide (Matthew Bender, New York, NY, 1993).