1997 Minnesota Statutes

     256L.12 Managed care. 

    Subdivision 1.    Selection of vendors.  In order to 
 contain costs, the commissioner of human services shall select 
 vendors of medical care who can provide the most economical care 
 consistent with high medical standards and shall, where 
 possible, contract with organizations on a prepaid capitation 
 basis to provide these services.  The commissioner shall 
 consider proposals by counties and vendors for managed care 
 plans which may include:  prepaid capitation programs, 
 competitive bidding programs, or other vendor payment mechanisms 
 designed to provide services in an economical manner or to 
 control utilization, with safeguards to ensure that necessary 
 services are provided.  

    Subd. 2.    Geographic area.  The commissioner shall 
 designate the geographic areas in which eligible individuals 
 must receive services through managed care plans. 

    Subd. 3.    Limitation of choice.  Persons enrolled in 
 the MinnesotaCare program who reside in the designated 
 geographic areas must enroll in a managed care plan to receive 
 their health care services.  Enrollees must receive their health 
 care services from health care providers who are part of the 
 managed care plan provider network, unless authorized by the 
 managed care plan, in cases of medical emergency, or when 
 otherwise required by law or by contract. 

    If only one managed care option is available in a 
 geographic area, the managed care plan may require that 
 enrollees designate a primary care provider from which to 
 receive their health care.  Enrollees will be permitted to 
 change their designated primary care provider upon request to 
 the managed care plan.  Requests to change primary care 
 providers may be limited to once annually.  If more than one 
 managed care plan is offered in a geographic area, enrollees 
 will be enrolled in a managed care plan for up to one year from 
 the date of enrollment, but shall have the right to change to 
 another managed care plan once within the first year of initial 
 enrollment.  Enrollees may also change to another managed care 
 plan during an annual 30-day open enrollment period.  Enrollees 
 shall be notified of the opportunity to change to another 
 managed care plan before the start of each annual open 
 enrollment period.  

    Enrollees may change managed care plans or primary care 
 providers at other than the above designated times for cause as 
 determined through an appeal pursuant to section 256.045. 

    Subd. 4.    Exemptions to limitations on choice.  All 
 contracts between the department of human services and prepaid 
 health plans to serve medical assistance, general assistance 
 medical care, and MinnesotaCare recipients must comply with the 
 requirements of United States Code, title 42, section 1396a 
 (a)(23)(B), notwithstanding any waivers authorized by the United 
 States Department of Health and Human Services pursuant to 
 United States Code, title 42, section 1315. 

    Subd. 5.    Eligibility for other state programs.  
 MinnesotaCare enrollees who become eligible for medical 
 assistance or general assistance medical care will remain in the 
 same managed care plan if the managed care plan has a contract 
 for that population.  Effective January 1, 1998, MinnesotaCare 
 enrollees who were formerly eligible for general assistance 
 medical care pursuant to section 256D.03, subdivision 3, within 
 six months of MinnesotaCare enrollment and were enrolled in a 
 prepaid health plan pursuant to section 256D.03, subdivision 4, 
 paragraph (d), must remain in the same managed care plan if the 
 managed care plan has a contract for that population.  Contracts 
 between the department of human services and managed care plans 
 must include MinnesotaCare, and medical assistance and may, at 
 the option of the commissioner of human services, also include 
 general assistance medical care. 

    Subd. 6.    Copayments and benefit limits.  Enrollees 
 are responsible for all copayments in section 256L.03, 
 subdivision 4, and shall pay copayments to the managed care plan 
 or to its participating providers.  The enrollee is also 
 responsible for payment of inpatient hospital charges which 
 exceed the MinnesotaCare benefit limit. 

    Subd. 7.    Managed care plan vendor requirements.  The 
 following requirements apply to all counties or vendors who 
 contract with the department of human services to serve 
 MinnesotaCare recipients.  Managed care plan contractors: 

    (1) shall authorize and arrange for the provision of the 
 full range of services listed in section 256L.03 in order to 
 ensure appropriate health care is delivered to enrollees; 

    (2) shall accept the prospective, per capita payment or 
 other contractually defined payment from the commissioner in 
 return for the provision and coordination of covered health care 
 services for eligible individuals enrolled in the program; 

    (3) may contract with other health care and social service 
 practitioners to provide services to enrollees; 

    (4) shall provide for an enrollee grievance process as 
 required by the commissioner and set forth in the contract with 
 the department; 

    (5) shall retain all revenue from enrollee copayments; 

    (6) shall accept all eligible MinnesotaCare enrollees, 
 without regard to health status or previous utilization of 
 health services; 

    (7) shall demonstrate capacity to accept financial risk 
 according to requirements specified in the contract with the 
 department.  A health maintenance organization licensed under 
 chapter 62D, or a nonprofit health plan licensed under chapter 
 62C, is not required to demonstrate financial risk capacity, 
 beyond that which is required to comply with chapters 62C and 
 62D; and 

    (8) shall submit information as required by the 
 commissioner, including data required for assessing enrollee 
 satisfaction, quality of care, cost, and utilization of services.

    Subd. 8.    Chemical dependency assessments.  The 
 managed care plan shall be responsible for assessing the need 
 and placement for chemical dependency services according to 
 criteria set forth in Minnesota Rules, parts 9530.6600 to 
 9530.6660. 

    Subd. 9.    Rate setting.  Rates will be prospective, 
 per capita, where possible.  The commissioner may allow health 
 plans to arrange for inpatient hospital services on a risk or 
 nonrisk basis.  The commissioner shall consult with an 
 independent actuary to determine appropriate rates. 

    Subd. 10.    Childhood immunization.  Each managed care 
 plan contracting with the department of human services under 
 this section shall collaborate with the local public health 
 agencies to ensure childhood immunization to all enrolled 
 families with children.  As part of this collaboration the plan 
 must provide the families with a recommended immunization 
 schedule. 

    HIST: 1993 c 345 art 9 s 10; 1994 c 625 art 8 s 58-60; 1995 c 
 234 art 6 s 17; 1997 c 225 art 1 s 16; art 2 s 56,62