HF 2604

Introduction - 94th Legislature (2025 - 2026)

Posted on 03/24/2025 04:30 p.m.

A bill for an act
relating to human services; establishing a medical assistance capitation payment
withhold related to verification of coverage; amending Minnesota Statutes 2024,
section 256B.69, subdivision 5a.

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

Section 1.

Minnesota Statutes 2024, 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:

(1) 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 for all personal care assistance services under section 256B.0659 and
community first services and supports under section 256B.85;

(2) by January 30 of each year that follows a rate increase for any aspect of services
under section 256B.0659 or 256B.85, inform the commissioner and the chairs and ranking
minority members of the legislative committees with jurisdiction over rates determined
under section 256B.851 of the amount of the rate increase that is paid to each personal care
assistance provider agency with which the plan has a contract; and

(3) use a six-month timely filing standard and provide an exemption to the timely filing
timeliness for the resubmission of claims where there has been a denial, request for more
information, or system issue.

(e) 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.

(f) 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.

(g) 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.

(h) 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.

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

(j) Managed care plans and county-based purchasing plans shall maintain current and
fully executed agreements for all subcontractors, including bargaining groups, for
administrative services that are expensed to the state's public health care programs.
Subcontractor agreements determined to be material, as defined by the commissioner after
taking into account state contracting and relevant statutory requirements, must be in the
form of a written instrument or electronic document containing the elements of offer,
acceptance, consideration, payment terms, scope, duration of the contract, and how the
subcontractor services relate to state public health care programs. Upon request, the
commissioner shall have access to all subcontractor documentation under this paragraph.
Nothing in this paragraph shall allow release of information that is nonpublic data pursuant
to section 13.02.

new text begin (k) Effective for services provided on or after January 1, 2026, through December 31,
2026, the commissioner shall withhold two percent of the capitation payment provided to
managed care plans under this section and county-based purchasing plans under section
256B.692 for each medical assistance enrollee. The withheld funds must be returned no
sooner than July 1 and no later than July 31 of the following year for capitation payments
for enrollees for whom the plan has submitted to the commissioner a verification of coverage
form completed and signed by the enrollee. The commissioner must develop the verification
of coverage form and make it available to managed care and county-based purchasing plans.
The form must require the enrollee to provide the enrollee's name and street address and
the name of the managed care or county-based purchasing plan selected by or assigned to
the enrollee and must include a signature block that allows the enrollee to attest that the
information provided is accurate. A plan must request all enrollees complete the verification
of coverage form and must submit all completed forms to the commissioner by February
27, 2026. If a completed form for an enrollee is not received by the commissioner by that
date, the commissioner:
new text end

new text begin (1) must not return money withheld for that enrollee to the plan;
new text end

new text begin (2) must cease making capitation payments to the plan for that enrollee, effective with
the April 2026 coverage month; and
new text end

new text begin (3) must disenroll the enrollee from medical assistance, subject to an enrollee appeal.
new text end