HF 1143

as introduced - 87th Legislature (2011 - 2012) Posted on 03/16/2011 09:38am

A bill for an act
relating to human services; requiring certain medical assistance enrollees and all
MinnesotaCare enrollees to receive basic services through an enrolled provider
network; providing major medical coverage to these enrollees; proposing coding
for new law in Minnesota Statutes, chapter 256B.

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

Section 1.

new text begin [256B.0758] ENROLLED PROVIDER NETWORKS; MAJOR
MEDICAL COVERAGE.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For purposes of this section, the following definitions
apply.
new text end

new text begin (b) "Demonstration provider" has the meaning provided in section 256B.69,
subdivision 2.
new text end

new text begin (c) "Enrolled provider network" means a health care provider or group of health care
providers that are accountable through a contract with the commissioner for: (1) the
quality and coordination of care provided under subdivision 3 to qualified enrollees; and
(2) managing the cost of providing this care.
new text end

new text begin (d) "Health plan company" has the meaning specified in section 62Q.01, subdivision
4.
new text end

new text begin (e) "Metropolitan statistical area" means a metropolitan area containing a core urban
area of 50,000 or more population, consisting of one or more counties including the
counties containing the core urban area, as well as any adjacent counties that have a high
degree of social and economic integration with the urban core.
new text end

new text begin (f) "Qualified enrollee" means an individual who is enrolled in medical assistance
under a families and children eligibility category, or as an adult without children under
section 256B.055, subdivision 15, or enrolled in the MinnesotaCare program under
chapter 256L.
new text end

new text begin Subd. 2. new text end

new text begin Establishment of reformed health care delivery system. new text end

new text begin (a) The
commissioner shall implement, by January 1, 2012, or upon federal approval, whichever
is later, a reformed health care delivery system for qualified medical assistance and
MinnesotaCare enrollees that delivers basic health care services through enrolled provider
networks in metropolitan statistical areas (MSAs), and supplements this coverage with
a major medical policy. Health care providers outside of a metropolitan statistical area
may serve as an enrolled provider network and receive total cost of care payments under
subdivision 3, or may choose to receive payments on a fee-for-service basis only.
new text end

new text begin (b) No later than July 1, 2012, or upon federal approval, the commissioner shall
discontinue contracts with managed care under sections 256B.69 and 256L.12 for the
provision of services to qualified enrollees.
new text end

new text begin Subd. 3. new text end

new text begin Provision of basic care services through enrolled provider networks.
new text end

new text begin (a) The commissioner shall enter into contracts with enrolled provider networks in
metropolitan statistical areas, and may enter into contracts with enrolled provider networks
outside of a metropolitan statistical area, to provide qualified enrollees with the basic care
services specified in paragraph (b), in return for receiving a per-enrollee, concurrently
risk-adjusted, total cost of care payment.
new text end

new text begin (b) Enrolled provider networks under contract with the commissioner shall provide,
contract for, and coordinate the following basic care services:
new text end

new text begin (1) preventive services;
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new text begin (2) inpatient hospital services, and physician and other health care professional
services associated with an inpatient hospital stay, subject to an annual limit of $.......;
new text end

new text begin (3) outpatient hospital services;
new text end

new text begin (4) freestanding ambulatory surgical center services;
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new text begin (5) outpatient physician and clinic visits;
new text end

new text begin (6) lab, x-ray, and diagnostic services;
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new text begin (7) diabetic care services;
new text end

new text begin (8) mental health care;
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new text begin (9) vision care, with eyeglasses covered as provided under subdivision 8;
new text end

new text begin (10) prescription drugs, subject to an annual limit of $.......;
new text end

new text begin (11) medication therapy management;
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new text begin (12) emergency room care;
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new text begin (13) immunizations and vaccines;
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new text begin (14) rehabilitative therapy;
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new text begin (15) urgent care;
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new text begin (16) home care; and
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new text begin (17) hospice care.
new text end

new text begin (c) An enrolled provider network may provide qualified enrollees with services that
are in addition to those listed in paragraph (b).
new text end

new text begin (d) No enrollee cost-sharing shall be applied to the services listed in paragraph (b).
new text end

new text begin (e) An enrolled provider network must coordinate the services provided under
paragraph (b) with any major medical services that an enrollee receives under subdivision
6.
new text end

new text begin (f) The commissioner shall, by competitive bid, award a contract with a health plan
company, county-based purchasing plan, or other entity to administer the provision of
basic care services by enrolled provider networks and administer fee-for-service payments
to providers who are not part of an enrolled provider network. The entity awarded the
contract must:
new text end

new text begin (1) collect data on the utilization and cost of health care services provided by each
enrolled provider network compared to providers who are not part of an enrolled provider
network, and on administrative and other costs incurred by enrolled provider network
compared to providers who are not part of an enrolled provider network, and make this
information available to enrolled provider networks and the commissioner;
new text end

new text begin (2) assist enrolled provider networks and the commissioner in identifying high-cost
enrollees;
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new text begin (3) track expenditures for services for which there are annual dollar limits, and
notify enrolled provider networks and the commissioner when an enrollee has reached a
service dollar limit;
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new text begin (4) evaluate the cost and quality of services provided by enrolled provider networks
in comparison to providers who are not part of an enrolled provider network, and report
this information to enrolled provider networks and the commissioner; and
new text end

new text begin (5) ensure access for enrollees to available enrolled provider networks and
fee-for-service providers. The administrator shall report to the commissioner any access
concerns which may arise under this reformed health care delivery system.
new text end

new text begin Data reported to the third-party administrator and the commissioner under this
paragraph are public data as defined in section 13.02, except that data on individuals are
classified as private data.
new text end

new text begin Subd. 4. new text end

new text begin Enrollee selection of enrolled provider network. new text end

new text begin (a) A qualified enrollee
within a metropolitan statistical area (MSA) must select an enrolled provider network in
order to receive services covered under this section. The commissioner shall assign an
enrollee to a enrolled provider network based on greatest percentage of services recently
provided to that enrollee, or proximity, if the enrollee does not make a choice. An enrollee
must agree to receive all nonemergency covered services through the enrolled provider
network, except for major medical services covered under subdivision 6 and services
provided on a fee-for-service basis under subdivision 8.
new text end

new text begin (b) An enrollee covered through an enrolled provider network and major medical
coverage has right to appeal to the commissioner according to section 256.045.
new text end

new text begin Subd. 5. new text end

new text begin Non-MSA providers. new text end

new text begin (a) A provider located outside of a metropolitan
statistical area shall be paid on a fee-for-service basis for covered services provided
to qualified enrollees, unless the provider is part of an enrolled provider network and
voluntarily chooses to participate under this section. Providers located outside of a
metropolitan statistical area may participate in county-based purchasing options in
collaboration with their county or a group of counties in the region.
new text end

new text begin (b) The commissioner of human services may consider other payment mechanisms
with providers that allow the commissioner to achieve cost-savings, including, but not
limited to, gain sharing arrangements with a county or group of providers, baskets of care,
and other payment mechanisms the commissioner determines would improve the quality
and efficiency of service delivery to qualified enrollees residing outside of a metropolitan
statistical area.
new text end

new text begin Subd. 6. new text end

new text begin Major medical coverage. new text end

new text begin (a) The commissioner shall, by competitive bid,
award a contract to a health plan company to provide to qualified enrollees statewide the
major medical policy specified in paragraph (b).
new text end

new text begin (b) The major medical policy must cover the following:
new text end

new text begin (1) inpatient hospital and associated physician and health professional costs that
in the aggregate exceed $....... per year;
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new text begin (2) physician and other health care professional costs not associated with an inpatient
hospital stay, that in the aggregate exceed $....... per year; and
new text end

new text begin (3) prescription drugs costs, that exceed $....... per year.
new text end

new text begin (c) The major medical policy must require providers who are not part of an enrolled
provider network who provide services to a qualified enrollee to coordinate these services
with those provided by the enrollee's enrolled provider network. The policy must also
provide an appeals mechanism for qualified enrollees.
new text end

new text begin (d) No enrollee cost-sharing shall apply to coverage under the major medical policy.
new text end

new text begin (e) The commissioner may require an enrolled provider network to enter into
a risk/gain-sharing agreement, under which the enrolled provider network shall be
financially responsible for a portion of the risk-adjusted major medical costs incurred by
qualified enrollees.
new text end

new text begin Subd. 7. new text end

new text begin Premiums. new text end

new text begin (a) MinnesotaCare enrollees receiving benefits under this
section must pay premiums as provided in section 256L.15.
new text end

new text begin (b) Medical assistance enrollees receiving benefits under this section shall pay
premiums based on the MinnesotaCare sliding premium scale, as established under
section 256L.15.
new text end

new text begin Subd. 8. new text end

new text begin Services provided through fee-for-service. new text end

new text begin The following services
provided to qualified enrollees shall be reimbursed on a fee-for-service basis by the entity
awarded the third-party administrator contract under subdivision 3:
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new text begin (1) emergency and nonemergency medical transportation services;
new text end

new text begin (2) alcohol and drug treatment;
new text end

new text begin (3) chiropractic care;
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new text begin (4) dental care, with dental services provided to nonpregnant adults subject to an
annual limit of $.......;
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new text begin (5) eyeglasses, subject to an annual limit of $.......;
new text end

new text begin (6) hearing aids;
new text end

new text begin (7) interpreter services;
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new text begin (8) medical equipment and supplies;
new text end

new text begin (9) prescriptions; and
new text end

new text begin (10) services provided in nursing facilities, intermediate facilities for persons with
development disabilities, and other long-term care settings.
new text end

new text begin Subd. 9. new text end

new text begin Other services for children. new text end

new text begin The medical assistance and MinnesotaCare
programs shall continue to cover, on a fee-for-service basis, health care services identified
as medically necessary for children as part of a child and teen checkup visit, if these
services are not covered under subdivision 3, 6, or 8.
new text end

new text begin Subd. 10. new text end

new text begin Retaliation prohibited. new text end

new text begin The commissioners of human services, health,
and commerce, as a condition of licensure or contract, shall prohibit health plan companies
and demonstration providers from retaliating against enrolled provider networks for
providing services under this section. For purposes of this prohibition, "retaliation"
includes, but is not limited to, reducing payment rates in other books of business, arranging
for network exclusions, or otherwise adversely changing contract terms.
new text end

new text begin Subd. 11. new text end

new text begin Federal approval. new text end

new text begin The commissioner shall seek any necessary federal
waivers and approvals necessary to implement this section.
new text end