Minnesota Legislature
SF 959
as introduced - 88th Legislature (2013 - 2014) Posted on 03/05/2013 08:28am
Current Version - as introduced
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A bill for an act
relating to human services; modifying medical assistance managed care
contracts; amending Minnesota Statutes 2012, section 256B.69, subdivision 5a.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
Section 1.
Minnesota Statutes 2012, 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 beginning
January 1, 1996. Managed care contracts which were in effect on June 30, 1995, and set to
renew on July 1, 1995, shall be renewed for the period July 1, 1995 through December
31, 1995 at the same terms that were in effect on June 30, 1995. 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) Effective for services rendered on or after January 1, 2003, 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) Effective for services rendered on or after January 1, 2009, through December
31, 2009, 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.
(e) Effective for services provided on or after January 1, deleted text begin 2010deleted text end new text begin 2014new text end , 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.0659deleted text end new text begin home care services
under section 256B.0651new text end .
(f) Effective for services rendered on or after January 1, 2010, through December
31, 2010, 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.
(g) Effective for services rendered on or after January 1, 2011, through December
31, 2011, the commissioner shall include as part of the performance targets described in
paragraph (c) a reduction in the health plan's emergency room utilization rate for state
health care program enrollees by a measurable rate of five percent from the plan's utilization
rate for state health care program enrollees for the previous calendar year. 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.
(h) 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 (i). 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.
(i) 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.
(j) Effective for services rendered on or after January 1, 2011, through December 31,
2011, 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.
(k) Effective for services rendered on or after January 1, 2012, through December
31, 2012, 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.
(l) 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.
(m) 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.
(n) 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.
(o) 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.
(p) The return of the withhold under paragraphs (d), (f), and (j) to (m) is not subject
to the requirements of paragraph (c).