SF 3149

Introduction - 94th Legislature (2025 - 2026)

Posted on 07/09/2025 09:11 a.m.

A bill for an act
relating to human services; establishing a county-administered rural medical
assistance program; establishing payment, coverage, and eligibility requirements
for the CARMA program; directing the commissioner of human services to seek
federal waivers; amending Minnesota Statutes 2024, section 256B.69, subdivision
3a; proposing coding for new law in Minnesota Statutes, chapter 256B.

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

Section 1.

Minnesota Statutes 2024, section 256B.69, subdivision 3a, is amended to read:

Subd. 3a.

County authority.

(a) The commissioner, when implementing the medical
assistance prepayment program within a county, must include the county board in the process
of development, approval, and issuance of the request for proposals to provide services to
eligible individuals within the proposed county. County boards must be given reasonable
opportunity to make recommendations regarding the development, issuance, review of
responses, and changes needed in the request for proposals. The commissioner must provide
county boards the opportunity to review each proposal based on the identification of
community needs under chapters 142F and 145A and county advocacy activities. If a county
board finds that a proposal does not address certain community needs, the county board and
commissioner shall continue efforts for improving the proposal and network prior to the
approval of the contract. The county board shall make recommendations regarding the
approval of local networks and their operations to ensure adequate availability and access
to covered services. The provider or health plan must respond directly to county advocates
and the state prepaid medical assistance ombudsperson regarding service delivery and must
be accountable to the state regarding contracts with medical assistance funds. The county
board may recommend a maximum number of participating health plans after considering
the size of the enrolling population; ensuring adequate access and capacity; considering the
client and county administrative complexity; and considering the need to promote the
viability of locally developed health plans. The county board or a single entity representing
a group of county boards and the commissioner shall mutually select health plans for
participation at the time of initial implementation of the prepaid medical assistance program
in that county or group of counties and at the time of contract renewal. The commissioner
shall also seek input for contract requirements from the county or single entity representing
a group of county boards at each contract renewal and incorporate those recommendations
into the contract negotiation process.

(b) At the option of the county board, the board may develop contract requirements
related to the achievement of local public health goals to meet the health needs of medical
assistance enrollees. These requirements must be reasonably related to the performance of
health plan functions and within the scope of the medical assistance benefit set. If the county
board and the commissioner mutually agree to such requirements, the department shall
include such requirements in all health plan contracts governing the prepaid medical
assistance program in that county at initial implementation of the program in that county
and at the time of contract renewal. The county board may participate in the enforcement
of the contract provisions related to local public health goals.

(c) For counties in which a prepaid medical assistance program has not been established,
the commissioner shall not implement that program if a county board submits an acceptable
and timely preliminary and final proposal under section 256B.692, until county-based
purchasing is no longer operational in that county. For counties in which a prepaid medical
assistance program is in existence on or after September 1, 1997, the commissioner must
terminate contracts with health plans according to section 256B.692, subdivision 5, if the
county board submits and the commissioner accepts a preliminary and final proposal
according to that subdivision. The commissioner is not required to terminate contracts that
begin on or after September 1, 1997, according to section 256B.692 until two years have
elapsed from the date of initial enrollment. new text begin This paragraph expires upon the effective date
of paragraph (d).
new text end

new text begin (d) Effective January 1, 2027, for counties in which a prepaid medical assistance program
is in existence on or after September 1, 1997, the commissioner must terminate contracts
with health plans according to section 256B.692, subdivision 5, if the county board submits
and the commissioner accepts a preliminary and final proposal according to that subdivision.
new text end

deleted text begin (d) deleted text end new text begin (e) new text end In the event that a county board or a single entity representing a group of county
boards and the commissioner cannot reach agreement regarding: (i) the selection of
participating health plans in that county; (ii) contract requirements; or (iii) implementation
and enforcement of county requirements including provisions regarding local public health
goals, the commissioner shall resolve all disputes after taking into account the
recommendations of a three-person mediation panel. The panel shall be composed of one
designee of the president of the association of Minnesota counties, one designee of the
commissioner of human services, and one person selected jointly by the designee of the
commissioner of human services and the designee of the Association of Minnesota Counties.
Within a reasonable period of time before the hearing, the panelists must be provided all
documents and information relevant to the mediation. The parties to the mediation must be
given 30 days' notice of a hearing before the mediation panel.

deleted text begin (e) deleted text end new text begin (f) new text end If a county which elects to implement county-based purchasing ceases to implement
county-based purchasing, it is prohibited from assuming the responsibility of county-based
purchasing for a period of five years from the date it discontinues purchasing.

deleted text begin (f) deleted text end new text begin (g) new text end The commissioner shall not require that contractual disputes between county-based
purchasing entities and the commissioner be mediated by a panel that includes a
representative of the Minnesota Council of Health Plans.

deleted text begin (g) deleted text end new text begin (h) new text end At the request of a county-purchasing entity, the commissioner shall adopt a
contract reprocurement or renewal schedule under which all counties included in the entity's
service area are reprocured or renewed at the same time.

deleted text begin (h) deleted text end new text begin (i) new text end The commissioner shall provide a written report under section 3.195 to the chairs
of the legislative committees having jurisdiction over human services in the senate and the
house of representatives describing in detail the activities undertaken by the commissioner
to ensure full compliance with this section. The report must also provide an explanation for
any decisions of the commissioner not to accept the recommendations of a county or group
of counties required to be consulted under this section. The report must be provided at least
30 days prior to the effective date of a new or renewed prepaid or managed care contract
in a county.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2027.
new text end

Sec. 2.

new text begin [256B.695] COUNTY-ADMINISTERED RURAL MEDICAL ASSISTANCE
PROGRAM.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For the purposes of this section, the following terms have
the meanings given.
new text end

new text begin (b) "CARMA" means the county-administered rural medical assistance program
established under this section.
new text end

new text begin (c) "Commissioner" means the commissioner of human services.
new text end

new text begin (d) "Eligible individual" means an individual who is:
new text end

new text begin (1) residing in a county administering CARMA; and
new text end

new text begin (2) eligible for medical assistance, MinnesotaCare, Minnesota Senior Health Options
(MSHO), Minnesota Senior Care Plus (MSC+), or Special Needs Basic Care (SNBC).
new text end

new text begin (e) "Enrollee" means an individual enrolled in CARMA.
new text end

new text begin (f) "PMAP" means the prepaid medical assistance program under section 256B.69.
new text end

new text begin (g) "Rural county" has the meaning given to "rural area" in Code of Federal Regulations,
title 42, section 438.52.
new text end

new text begin Subd. 2. new text end

new text begin Program established. new text end

new text begin A county-administered rural medical assistance program
is established to:
new text end

new text begin (1) provide a county-owned and county-administered alternative to PMAP;
new text end

new text begin (2) facilitate integration of health care, public health, and social services to address
health-related social needs in rural communities;
new text end

new text begin (3) account for the fewer enrollees and local providers of health care and community
services in rural communities; and
new text end

new text begin (4) promote accountability for health outcomes, health equity, customer service,
community outreach, and cost of care.
new text end

new text begin Subd. 3. new text end

new text begin County participation. new text end

new text begin Each county or group of counties authorized under
section 256B.692 may administer CARMA for any or all eligible individuals as an alternative
to PMAP, MinnesotaCare, MSHO, MSC+, or SNBC programs. Counties choosing and
authorized to administer CARMA are exempt from the procurement process as required
under section 256B.69.
new text end

new text begin Subd. 4. new text end

new text begin Oversight and regulation. new text end

new text begin CARMA is governed by sections 256B.69 and
256B.692, unless otherwise provided for under this section. The commissioner must develop
and implement a procurement process requiring applications from county-based purchasing
plans interested in offering CARMA. The procurement process must require county-based
purchasing plans to demonstrate compliance with federal and state regulatory requirements
and the ability to meet the goals of the program set forth in subdivision 2. The commissioner
must review and approve or disapprove applications.
new text end

new text begin Subd. 5. new text end

new text begin CARMA enrollment. new text end

new text begin (a) Subject to paragraphs (d) and (e), eligible individuals
must be automatically enrolled in CARMA, but may decline enrollment. Eligible individuals
may enroll in fee-for-service medical assistance. Eligible individuals may change their
CARMA elections on an annual basis.
new text end

new text begin (b) Eligible individuals must be able to enroll in CARMA through the selection process
in accordance with the election period established in section 256B.69, subdivision 4,
paragraph (e).
new text end

new text begin (c) Enrollees who were not previously enrolled in the medical assistance program or
MinnesotaCare can change their selection once within the first year after enrollment in
CARMA. Enrollees who were not previously in CARMA have 90 days to make a change
and changes are allowed for additional special circumstances.
new text end

new text begin (d) The commissioner may offer a second health plan other than, and in addition to,
CARMA to eligible individuals when another health plan is required by federal law or rule.
The commissioner may offer a replacement plan to eligible individuals, as determined by
the commissioner, when counties administering CARMA have their contract terminated
for cause.
new text end

new text begin (e) The commissioner may, on a county-by-county basis, offer a health plan other than,
and in addition to, CARMA to individuals who are eligible for both Medicare and medical
assistance due to age or disability if the commissioner deems it necessary for enrollees to
have another choice of health plan. Factors the commissioner must consider when
determining if the other health plan is necessary include the number of available Medicare
Advantage Plan options that are not special needs plans in the county, the size of the enrolling
population, the additional administrative burden placed on providers and counties by multiple
health plan options in a county, the need to ensure the viability and success of the CARMA
program, and the impact to the medical assistance program.
new text end

new text begin (f) In counties where the commissioner is required by federal law or elects to offer a
second health plan other than CARMA pursuant to paragraphs (d) and (e), eligible enrollees
who do not select a health plan at the time of enrollment must automatically be enrolled in
CARMA.
new text end

new text begin (g) This subdivision supersedes section 256B.694.
new text end

new text begin Subd. 6. new text end

new text begin Benefits and services. new text end

new text begin (a) County entities administering CARMA must cover
all benefits and services required to be covered by medical assistance under section
256B.0625.
new text end

new text begin (b) County entities administering CARMA may include health-related social needs
(HRSN) benefits as covered services under medical assistance as of January 1, 2030.
Coverage for HRSN must be based on the assessed needs of housing, food, transportation,
utilities, and interpersonal safety.
new text end

new text begin (c) County entities administering CARMA may reimburse enrollees directly for
out-of-pocket costs incurred obtaining assessed HRSN services provided by nontraditional
providers who are unable to accept payment via traditional health insurance methods.
Enrollees must not be reimbursed for out-of-pocket costs paid to providers eligible to enroll.
new text end

new text begin Subd. 7. new text end

new text begin Payment. new text end

new text begin (a) The commissioner, in consultation with counties administering
CARMA, must develop a mechanism for the payment of county entities administering
CARMA. The payment mechanism must:
new text end

new text begin (1) be governed by contracts with terms, including but not limited to payment rates,
amended on an as-needed basis;
new text end

new text begin (2) pay a full-risk monthly capitation payment for services included in CARMA, including
the cost for administering CARMA benefits and services;
new text end

new text begin (3) include risk corridors based on minimum loss ratio, total cost of care, or other metrics;
new text end

new text begin (4) include a settle-up process tied to the risk corridor arrangement allowing a county
entity administering CARMA to retain savings for reinvestment in health care activities
and operations to protect against significant losses that a county entity administering CARMA
or the state might realize, beginning no sooner than after the county-entity's third year of
CARMA operations;
new text end

new text begin (5) include a collaborative rate-setting process accounting for CARMA experience,
regional experience, and the Department of Human Services fee-for-service experience;
and
new text end

new text begin (6) be exempt from section 256B.69, subdivisions 5a, paragraphs (c) and (f), and 5d,
and payment for Medicaid services provided under section 256B.69, subdivision 28,
paragraph (b), no sooner than three years after CARMA implementation.
new text end

new text begin (b) Payments for benefits and services under subdivision 6, paragraph (a), must not
exceed payments that otherwise would have been paid to health plans under medical
assistance for that county or region. Payments for HRSN benefits under subdivision 6,
paragraph (b), must be in addition to payments for benefits and services under subdivision
6, paragraph (a).
new text end

new text begin Subd. 8. new text end

new text begin Quality measures. new text end

new text begin (a) The commissioner and county entities administering
CARMA must collaborate to establish quality measures for CARMA not to exceed the
extent of quality measures required under sections 256B.69 and 256B.692. The measures
must include:
new text end

new text begin (1) enrollee experience and outcomes;
new text end

new text begin (2) population health;
new text end

new text begin (3) health equity; and
new text end

new text begin (4) the value of health care spending.
new text end

new text begin (b) The commissioner and county entities administering CARMA must collaborate to
define a quality improvement model for CARMA. The model must include a focus on
locally specified measures based on the counties' unique needs. The locally specified
measures for the county entity administering CARMA must be determined before the
commissioner enters into any contract with the county entity.
new text end

new text begin Subd. 9. new text end

new text begin Data and systems integration. new text end

new text begin The commissioner and county entities
administering CARMA must collaborate to:
new text end

new text begin (1) identify and address barriers that prevent county entities administering CARMA
from reviewing individual enrollee eligibility information to identify eligibility and to help
enrollees apply for other appropriate programs and resources;
new text end

new text begin (2) identify and address barriers preventing county entities administering CARMA from
more readily communicating with and educating potential and current enrollees regarding
other program opportunities, including helping enrollees apply for those programs and
navigate transitions between programs;
new text end

new text begin (3) develop and test, in counties participating in CARMA, a universal public assistance
application form to reduce the administrative barriers associated with applying for and
participating in various public programs;
new text end

new text begin (4) identify and address regulatory and system barriers that may prohibit county entities
administering CARMA, agencies, and other partners from working together to identify and
address an individual's needs;
new text end

new text begin (5) facilitate greater interoperability between county entities administering CARMA,
agencies, and other partners to send and receive the data necessary to support CARMA,
counties, and local health system efforts to improve the health and welfare of prospective
and enrolled populations;
new text end

new text begin (6) support efforts of county entities administering CARMA to incorporate the necessary
automation and interoperability to eliminate manual processes when related to the data
exchanged; and
new text end

new text begin (7) support the creation and maintenance by county entities administering CARMA of
an updated electronic inventory of community resources available to assist the enrollee in
the enrollee's HRSN, including an electronic closed-loop referral system.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2027.
new text end

Sec. 3. new text begin REQUEST FOR FEDERAL WAIVER.
new text end

new text begin The commissioner of human services must seek all federal waivers and authority
necessary to implement CARMA. Any part of the CARMA program that does not require
federal approval shall have an effective date as specified in state law. The commissioner of
human services shall notify the revisor of statutes when federal approval is obtained.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end