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
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
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
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 (c), must
remain in the same managed care plan if the managed care plan has a contract for that population.
Managed care plans must participate in the MinnesotaCare and general assistance medical care
programs under a contract with the Department of Human Services in service areas where they
participate in the medical assistance program.
Subd. 6. Co-payments and benefit limits.
Enrollees are responsible for all co-payments in
256L.03, subdivision 5
, and shall pay co-payments 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
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
(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 co-payments;
(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
Subd. 9. Rate setting; performance withholds.
(a) 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.
(b) For services rendered on or after January 1, 2003, to December 31, 2003, the
commissioner shall withhold .5 percent of managed care plan payments under this section pending
completion of performance targets. The withheld funds must be returned no sooner than July 1
and no later than July 31 of the following year if performance targets in the contract are achieved.
A managed care plan may include as admitted assets under section
any amount withheld
under this paragraph that is reasonably expected to be returned.
(c) For services rendered on or after January 1, 2004, the commissioner shall withhold five
percent of managed care plan payments under this section 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. The withheld funds must be returned no sooner than July 1 and no later
than July 31 of the following calendar year if performance targets in the contract are achieved.
A managed care plan or a county-based purchasing plan under section
as admitted assets under section
any amount withheld under this paragraph that is
reasonably expected to be returned.
Subd. 9a. Rate setting; ratable reduction.
For services rendered on or after October 1,
2003, the total payment made to managed care plans under the MinnesotaCare program is reduced
1.0 percent. This provision excludes payments for mental health services added as covered
benefits after December 31, 2007.
Subd. 9b. Rate setting; ratable reduction.
In addition to the reduction in subdivision
9a, the total payment made to managed care plans under the MinnesotaCare program shall be
reduced for services provided on or after January 1, 2006, to reflect a 6.0 percent reduction in
reimbursement for inpatient hospital services.
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.
Subd. 11. Coverage at Indian health service facilities.
For American Indian enrollees of
MinnesotaCare, MinnesotaCare shall cover health care services provided at Indian health service
facilities and facilities operated by a tribe or tribal organization under funding authorized by
United States Code, title 25, sections 450f to 450n, or title III of the Indian Self-Determination and
Education Act, Public Law 93-638, if those services would otherwise be covered under section
. Payments for services provided under this subdivision shall be made on a fee-for-service
basis, and may, at the option of the tribe or organization, be made at the rates authorized under
256.969, subdivision 16
256B.0625, subdivision 34
, for those MinnesotaCare
enrollees eligible for coverage at medical assistance rates. For purposes of this subdivision,
"American Indian" has the meaning given to persons to whom services will be provided for in
Code of Federal Regulations, title 42, section
History: 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; 1998 c 407 art 5 s 38; 1Sp2001 c 9 art 2 s 64; 2002 c 220 art 15 s 23;
2002 c 375 art 2 s 46; 2002 c 379 art 1 s 113; 1Sp2003 c 14 art 12 s 80-82; 2004 c 228 art 1 s 75;
1Sp2005 c 4 art 8 s 73; 2007 c 147 art 8 s 31