HF 1010

as introduced - 89th Legislature (2015 - 2016) Posted on 02/18/2015 11:17am

A bill for an act
relating to human services; modifying medical assistance managed care
contracts; amending Minnesota Statutes 2014, section 256B.69, subdivision 5a.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2014, section 256B.69, subdivision 5a, is amended to
read:

Subd. 5a.

Managed care contracts.

(a) Managed care contracts under this section
and section 256L.12 shall be entered into or renewed on a calendar year basis. The
commissioner may issue separate contracts with requirements specific to services to
medical assistance recipients age 65 and older.

(b) A prepaid health plan providing covered health services for eligible persons
pursuant to chapters 256B and 256L is responsible for complying with the terms of its
contract with the commissioner. Requirements applicable to managed care programs
under chapters 256B and 256L established after the effective date of a contract with the
commissioner take effect when the contract is next issued or renewed.

(c) The commissioner shall withhold five percent of managed care plan payments
under this section and county-based purchasing plan payments under section 256B.692
for the prepaid medical assistance program pending completion of performance targets.
Each performance target must be quantifiable, objective, measurable, and reasonably
attainable, except in the case of a performance target based on a federal or state law
or rule. Criteria for assessment of each performance target must be outlined in writing
prior to the contract effective date. Clinical or utilization performance targets and their
related criteria must consider evidence-based research and reasonable interventions when
available or applicable to the populations served, and must be developed with input from
external clinical experts and stakeholders, including managed care plans, county-based
purchasing plans, and providers. The managed care or county-based purchasing plan
must demonstrate, to the commissioner's satisfaction, that the data submitted regarding
attainment of the performance target is accurate. The commissioner shall periodically
change the administrative measures used as performance targets in order to improve plan
performance across a broader range of administrative services. The performance targets
must include measurement of plan efforts to contain spending on health care services and
administrative activities. The commissioner may adopt plan-specific performance targets
that take into account factors affecting only one plan, including characteristics of the
plan's enrollee population. The withheld funds must be returned no sooner than July of the
following year if performance targets in the contract are achieved. The commissioner may
exclude special demonstration projects under subdivision 23.

(d) The commissioner shall require that managed care plans use the assessment and
authorization processes, forms, timelines, standards, documentation, and data reporting
requirements, protocols, billing processes, and policies consistent with medical assistance
fee-for-service or the Department of Human Services contract requirements consistent
with medical assistance fee-for-service or the Department of Human Services contract
requirements for all deleted text begin personal care assistance services under section 256B.0659 deleted text end new text begin home care
services under section 256B.0651 new text end .

(e) Effective for services rendered on or after January 1, 2012, the commissioner
shall include as part of the performance targets described in paragraph (c) a reduction
in the health plan's emergency department utilization rate for medical assistance and
MinnesotaCare enrollees, as determined by the commissioner. For 2012, the reduction
shall be based on the health plan's utilization in 2009. To earn the return of the withhold
each subsequent year, the managed care plan or county-based purchasing plan must
achieve a qualifying reduction of no less than ten percent of the plan's emergency
department utilization rate for medical assistance and MinnesotaCare enrollees, excluding
enrollees in programs described in subdivisions 23 and 28, compared to the previous
measurement year until the final performance target is reached. When measuring
performance, the commissioner must consider the difference in health risk in a managed
care or county-based purchasing plan's membership in the baseline year compared to the
measurement year, and work with the managed care or county-based purchasing plan to
account for differences that they agree are significant.

The withheld funds must be returned no sooner than July 1 and no later than July 31
of the following calendar year if the managed care plan or county-based purchasing plan
demonstrates to the satisfaction of the commissioner that a reduction in the utilization rate
was achieved. The commissioner shall structure the withhold so that the commissioner
returns a portion of the withheld funds in amounts commensurate with achieved reductions
in utilization less than the targeted amount.

The withhold described in this paragraph shall continue for each consecutive contract
period until the plan's emergency room utilization rate for state health care program
enrollees is reduced by 25 percent of the plan's emergency room utilization rate for medical
assistance and MinnesotaCare enrollees for calendar year 2009. Hospitals shall cooperate
with the health plans in meeting this performance target and shall accept payment
withholds that may be returned to the hospitals if the performance target is achieved.

(f) Effective for services rendered on or after January 1, 2012, the commissioner
shall include as part of the performance targets described in paragraph (c) a reduction
in the plan's hospitalization admission rate for medical assistance and MinnesotaCare
enrollees, as determined by the commissioner. To earn the return of the withhold each
year, the managed care plan or county-based purchasing plan must achieve a qualifying
reduction of no less than five percent of the plan's hospital admission rate for medical
assistance and MinnesotaCare enrollees, excluding enrollees in programs described in
subdivisions 23 and 28, compared to the previous calendar year until the final performance
target is reached. When measuring performance, the commissioner must consider the
difference in health risk in a managed care or county-based purchasing plan's membership
in the baseline year compared to the measurement year, and work with the managed care
or county-based purchasing plan to account for differences that they agree are significant.

The withheld funds must be returned no sooner than July 1 and no later than July
31 of the following calendar year if the managed care plan or county-based purchasing
plan demonstrates to the satisfaction of the commissioner that this reduction in the
hospitalization rate was achieved. The commissioner shall structure the withhold so that
the commissioner returns a portion of the withheld funds in amounts commensurate with
achieved reductions in utilization less than the targeted amount.

The withhold described in this paragraph shall continue until there is a 25 percent
reduction in the hospital admission rate compared to the hospital admission rates in
calendar year 2011, as determined by the commissioner. The hospital admissions in this
performance target do not include the admissions applicable to the subsequent hospital
admission performance target under paragraph (g). Hospitals shall cooperate with the
plans in meeting this performance target and shall accept payment withholds that may be
returned to the hospitals if the performance target is achieved.

(g) Effective for services rendered on or after January 1, 2012, the commissioner
shall include as part of the performance targets described in paragraph (c) a reduction in
the plan's hospitalization admission rates for subsequent hospitalizations within 30 days of
a previous hospitalization of a patient regardless of the reason, for medical assistance and
MinnesotaCare enrollees, as determined by the commissioner. To earn the return of the
withhold each year, the managed care plan or county-based purchasing plan must achieve
a qualifying reduction of the subsequent hospitalization rate for medical assistance and
MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions 23
and 28, of no less than five percent compared to the previous calendar year until the
final performance target is reached.

The withheld funds must be returned no sooner than July 1 and no later than July
31 of the following calendar year if the managed care plan or county-based purchasing
plan demonstrates to the satisfaction of the commissioner that a qualifying reduction in
the subsequent hospitalization rate was achieved. The commissioner shall structure the
withhold so that the commissioner returns a portion of the withheld funds in amounts
commensurate with achieved reductions in utilization less than the targeted amount.

The withhold described in this paragraph must continue for each consecutive
contract period until the plan's subsequent hospitalization rate for medical assistance and
MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions 23
and 28, is reduced by 25 percent of the plan's subsequent hospitalization rate for calendar
year 2011. Hospitals shall cooperate with the plans in meeting this performance target and
shall accept payment withholds that must be returned to the hospitals if the performance
target is achieved.

(h) Effective for services rendered on or after January 1, 2013, through December
31, 2013, the commissioner shall withhold 4.5 percent of managed care plan payments
under this section and county-based purchasing plan payments under section 256B.692
for the prepaid medical assistance program. The withheld funds must be returned no
sooner than July 1 and no later than July 31 of the following year. The commissioner may
exclude special demonstration projects under subdivision 23.

(i) Effective for services rendered on or after January 1, 2014, the commissioner
shall withhold three percent of managed care plan payments under this section and
county-based purchasing plan payments under section 256B.692 for the prepaid medical
assistance program. The withheld funds must be returned no sooner than July 1 and
no later than July 31 of the following year. The commissioner may exclude special
demonstration projects under subdivision 23.

(j) A managed care plan or a county-based purchasing plan under section 256B.692
may include as admitted assets under section 62D.044 any amount withheld under this
section that is reasonably expected to be returned.

(k) Contracts between the commissioner and a prepaid health plan are exempt from
the set-aside and preference provisions of section 16C.16, subdivisions 6, paragraph
(a), and 7.

(l) The return of the withhold under paragraphs (h) and (i) is not subject to the
requirements of paragraph (c).

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2016.
new text end