Bill Text: MN SF1467 | 2011-2012 | 87th Legislature | Introduced
Bill Title: Managed care plans and county-based purchasing plans administrative costs reduction
Sponsorship: Partisan Bill (Democrat 2)
Status: (Introduced - Dead) 2011-05-22 - Referred to Health and Human Services [SF1467 Detail]
Download: Minnesota-2011-SF1467-Introduced.html
1.2relating to human services; reducing the administrative costs to managed care
1.3plans and county-based purchasing plans under the medical assistance program
1.4and the administrative payments to third-party administrators that administer
1.5the state employee group insurance plan; modifying personal care assistance
1.6services; creating a withhold to managed care plans and county-based purchasing
1.7plans for reducing hospitalizations; modifying the emergency room utilization
1.8rate withhold to managed care plans; delaying capitation payments for single
1.9adults without children in MinnesotaCare; creating demonstration projects for
1.10the delivery of health care services to certain medical assistance populations;
1.11limiting home and community-based waiver services allocations; requiring the
1.12commissioner of human services to issue a request for proposals to provide
1.13claims processing services for the fee-for-service medical assistance program;
1.14amending Minnesota Statutes 2010, sections 43A.23, subdivision 1; 256B.0625,
1.15subdivision 19a; 256B.0652, subdivision 6; 256B.69, subdivisions 5a, 5i, 28;
1.16256L.12, subdivision 9; Laws 2009, chapter 79, article 13, section 3, subdivision
1.178, as amended.
1.18BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.19 Section 1. Minnesota Statutes 2010, section 43A.23, subdivision 1, is amended to read:
1.20 Subdivision 1. General. (a) The commissioner is authorized to request proposals
1.21or to negotiate and to enter into contracts with parties which in the judgment of the
1.22commissioner are best qualified to provide service to the benefit plans. Contracts entered
1.23into are not subject to the requirements of sections16C.16 to
16C.19 . The commissioner
1.24may negotiate premium rates and coverage. The commissioner shall consider the cost of
1.25the plans, conversion options relating to the contracts, service capabilities, character,
1.26financial position, and reputation of the carriers, and any other factors which the
1.27commissioner deems appropriate. Each benefit contract must be for a uniform term of at
1.28least one year, but may be made automatically renewable from term to term in the absence
2.1of notice of termination by either party. A carrier licensed under chapter 62A is exempt
2.2from the taxes imposed by chapter 297I on premiums paid to it by the state.
2.3 (b) All self-insured hospital and medical service products must comply with coverage
2.4mandates, data reporting, and consumer protection requirements applicable to the licensed
2.5carrier administering the product, had the product been insured, including chapters 62J,
2.662M, and 62Q. Any self-insured products that limit coverage to a network of providers
2.7or provide different levels of coverage between network and nonnetwork providers shall
2.8comply with section62D.123 and geographic access standards for health maintenance
2.9organizations adopted by the commissioner of health in rule under chapter 62D.
2.10 (c) Notwithstanding paragraph (b), a self-insured hospital and medical product
2.11offered under sections43A.22 to
43A.30 is not required to extend dependent coverage to
2.12an eligible employee's unmarried child under the age of 25 to the full extent required under
2.13chapters 62A and 62L. Dependent coverage must, at a minimum, extend to an eligible
2.14employee's unmarried child who is under the age of 19 or an unmarried child under the
2.15age of 25 who is a full-time student. A person who is at least 19 years of age but who is
2.16under the age of 25 and who is not a full-time student must be permitted to be enrolled as
2.17a dependent of an eligible employee until age 25 if the person:
2.18(1) was a full-time student immediately prior to being ordered into active military
2.19service, as defined in section190.05, subdivision 5b or 5c;
2.20(2) has been separated or discharged from active military service; and
2.21(3) would be eligible to enroll as a dependent of an eligible employee, except that
2.22the person is not a full-time student.
2.23The definition of "full-time student" for purposes of this paragraph includes any student
2.24who by reason of illness, injury, or physical or mental disability as documented by
2.25a physician is unable to carry what the educational institution considers a full-time
2.26course load so long as the student's course load is at least 60 percent of what otherwise
2.27is considered by the institution to be a full-time course load. Any notice regarding
2.28termination of coverage due to attainment of the limiting age must include information
2.29about this definition of "full-time student."
2.30 (d) Beginning January 1, 2010, the health insurance benefit plans offered in the
2.31commissioner's plan under section43A.18, subdivision 2 , and the managerial plan under
2.32section43A.18, subdivision 3 , must include an option for a health plan that is compatible
2.33with the definition of a high-deductible health plan in section 223 of the United States
2.34Internal Revenue Code.
2.35(e) Beginning January 1, 2011, any contract entered into by the commissioner with
2.36a licensed carrier or third-party administrator to administer the health insurance benefit
3.1plans offered under sections 43A.22 to 43A.30 shall reflect a reduction in administrative
3.2costs that equals a per enrollee per month reduction of 21 cents.
3.3 Sec. 2. Minnesota Statutes 2010, section 256B.0625, subdivision 19a, is amended to
3.4read:
3.5 Subd. 19a. Personal care assistance services. Medical assistance covers personal
3.6care assistance services in a recipient's home. Effective January 1, 2010, to qualify for
3.7personal care assistance services, a recipient must require assistance and be determined
3.8dependent in one activity of daily living as defined in section256B.0659, subdivision 1 ,
3.9paragraph (b), or in a Level I behavior as defined in section256B.0659, subdivision 1 ,
3.10paragraph (c).Beginning July 1, 2011, to qualify for personal care assistance services, a
3.11recipient must require assistance and be determined dependent in at least two activities
3.12of daily living as defined in section
256B.0659. Recipients or responsible parties must
3.13be able to identify the recipient's needs, direct and evaluate task accomplishment, and
3.14provide for health and safety. Approved hours may be used outside the home when normal
3.15life activities take them outside the home. To use personal care assistance services at
3.16school, the recipient or responsible party must provide written authorization in the care
3.17plan identifying the chosen provider and the daily amount of services to be used at school.
3.18Total hours for services, whether actually performed inside or outside the recipient's
3.19home, cannot exceed that which is otherwise allowed for personal care assistance services
3.20in an in-home setting according to sections256B.0651 to
256B.0656 . Medical assistance
3.21does not cover personal care assistance services for residents of a hospital, nursing facility,
3.22intermediate care facility, health care facility licensed by the commissioner of health, or
3.23unless a resident who is otherwise eligible is on leave from the facility and the facility
3.24either pays for the personal care assistance services or forgoes the facility per diem for the
3.25leave days that personal care assistance services are used. All personal care assistance
3.26services must be provided according to sections256B.0651 to
256B.0656 . Personal care
3.27assistance services may not be reimbursed if the personal care assistant is the spouse or
3.28paid guardian of the recipient or the parent of a recipient under age 18, or the responsible
3.29party or the family foster care provider of a recipient who cannot direct the recipient's own
3.30care unless, in the case of a foster care provider, a county or state case manager visits
3.31the recipient as needed, but not less than every six months, to monitor the health and
3.32safety of the recipient and to ensure the goals of the care plan are met. Notwithstanding
3.33the provisions of section256B.0659 , the unpaid guardian or conservator of an adult,
3.34who is not the responsible party and not the personal care provider organization, may be
3.35reimbursed to provide personal care assistance services to the recipient if the guardian or
4.1conservator meets all criteria for a personal care assistant according to section256B.0659 ,
4.2and shall not be considered to have a service provider interest for purposes of participation
4.3on the screening team under section256B.092, subdivision 7 .
4.4 Sec. 3. Minnesota Statutes 2010, section 256B.0652, subdivision 6, is amended to read:
4.5 Subd. 6. Authorization; personal care assistance and qualified professional.
4.6 (a) All personal care assistance services, supervision by a qualified professional, and
4.7additional services beyond the limits established in subdivision 11, must be authorized
4.8by the commissioner or the commissioner's designee before services begin except for the
4.9assessments established in subdivision 11 and section256B.0911 . The authorization for
4.10personal care assistance and qualified professional services under section256B.0659 must
4.11be completed within 30 days after receiving a complete request.
4.12 (b) The amount of personal care assistance services authorized must be based
4.13on the recipient's home care rating. The home care rating shall be determined by the
4.14commissioner or the commissioner's designee based on information submitted to the
4.15commissioner identifying the following for recipients with dependencies in two or more
4.16activities of daily living:
4.17 (1) total number of dependencies of activities of daily living as defined in section
4.18256B.0659
;
4.19 (2) presence of complex health-related needs as defined in section256B.0659 ; and
4.20 (3) presence of Level I behavior as defined in section256B.0659 .
4.21 (c) For persons meeting the criteria in paragraph (b), the methodology to determine
4.22total time for personal care assistance services for each home care rating is based on
4.23the median paid units per day for each home care rating from fiscal year 2007 data for
4.24the personal care assistance program. Each home care rating has a base level of hours
4.25assigned. Additional time is added through the assessment and identification of the
4.26following:
4.27 (1) 30 additional minutes per day for a dependency in each critical activity of daily
4.28living as defined in section256B.0659 ;
4.29 (2) 30 additional minutes per day for each complex health-related function as
4.30defined in section256B.0659 ; and
4.31 (3) 30 additional minutes per day for each behavior issue as defined in section
4.32256B.0659
, subdivision 4, paragraph (d).
4.33 (d) Effective July 1, 2011, the home care rating for recipients who have a dependency
4.34in one activity of daily living or level one behavior shall equal no more than two units per
5.1day. Recipients with this home care rating are not subject to the methodology in paragraph
5.2(c), and are not eligible for more than two units per day.
5.3(e) A limit of 96 units of qualified professional supervision may be authorized for
5.4each recipient receiving personal care assistance services. A request to the commissioner
5.5to exceed this total in a calendar year must be requested by the personal care provider
5.6agency on a form approved by the commissioner.
5.7 Sec. 4. Minnesota Statutes 2010, section 256B.69, subdivision 5a, is amended to read:
5.8 Subd. 5a. Managed care contracts. (a) Managed care contracts under this section
5.9and section256L.12 shall be entered into or renewed on a calendar year basis beginning
5.10January 1, 1996. Managed care contracts which were in effect on June 30, 1995, and set to
5.11renew on July 1, 1995, shall be renewed for the period July 1, 1995 through December
5.1231, 1995 at the same terms that were in effect on June 30, 1995. The commissioner may
5.13issue separate contracts with requirements specific to services to medical assistance
5.14recipients age 65 and older.
5.15 (b) A prepaid health plan providing covered health services for eligible persons
5.16pursuant to chapters 256B and 256L is responsible for complying with the terms of its
5.17contract with the commissioner. Requirements applicable to managed care programs
5.18under chapters 256B and 256L established after the effective date of a contract with the
5.19commissioner take effect when the contract is next issued or renewed.
5.20 (c) Effective for services rendered on or after January 1, 2003, the commissioner
5.21shall withhold five percent of managed care plan payments under this section and
5.22county-based purchasing plan payments under section256B.692 for the prepaid medical
5.23assistance program pending completion of performance targets. Each performance target
5.24must be quantifiable, objective, measurable, and reasonably attainable, except in the case
5.25of a performance target based on a federal or state law or rule. Criteria for assessment
5.26of each performance target must be outlined in writing prior to the contract effective
5.27date. The managed care plan must demonstrate, to the commissioner's satisfaction,
5.28that the data submitted regarding attainment of the performance target is accurate. The
5.29commissioner shall periodically change the administrative measures used as performance
5.30targets in order to improve plan performance across a broader range of administrative
5.31services. The performance targets must include measurement of plan efforts to contain
5.32spending on health care services and administrative activities. The commissioner may
5.33adopt plan-specific performance targets that take into account factors affecting only one
5.34plan, including characteristics of the plan's enrollee population. The withheld funds
5.35must be returned no sooner than July of the following year if performance targets in the
6.1contract are achieved. The commissioner may exclude special demonstration projects
6.2under subdivision 23.
6.3 (d) Effective for services rendered on or after January 1, 2009, through December
6.431, 2009, the commissioner shall withhold three percent of managed care plan payments
6.5under this section and county-based purchasing plan payments under section256B.692
6.6for the prepaid medical assistance program. The withheld funds must be returned no
6.7sooner than July 1 and no later than July 31 of the following year. The commissioner may
6.8exclude special demonstration projects under subdivision 23.
6.9(e) Effective for services provided on or after January 1, 2010, the commissioner
6.10shall require that managed care plans use the assessment and authorization processes,
6.11forms, timelines, standards, documentation, and data reporting requirements, protocols,
6.12billing processes, and policies consistent with medical assistance fee-for-service or the
6.13Department of Human Services contract requirements consistent with medical assistance
6.14fee-for-service or the Department of Human Services contract requirements for all
6.15personal care assistance services under section256B.0659 .
6.16(f) Effective for services rendered on or after January 1, 2010, through December
6.1731, 2010, the commissioner shall withhold 4.5 percent of managed care plan payments
6.18under this section and county-based purchasing plan payments under section256B.692
6.19for the prepaid medical assistance program. The withheld funds must be returned no
6.20sooner than July 1 and no later than July 31 of the following year. The commissioner may
6.21exclude special demonstration projects under subdivision 23.
6.22(g) Effective for services rendered on or after January 1, 2011, through December
6.2331, 2011, the commissioner shall include as part of the performance targets described
6.24in paragraph (c) a reduction in the health plan's emergency room utilization rate for
6.25state health care program enrollees by a measurable rate of five percent from the plan's
6.26utilization rate for state health care program enrollees for the previous calendar year.
6.27Effective for services rendered on or after January 1, 2012, the commissioner shall
6.28include as part of the performance targets described in paragraph (c) a reduction in the
6.29health plan's emergency room utilization rate for state health care program enrollees by a
6.30measurable rate of ten percent from the plan's utilization rate for state health care program
6.31enrollees for the previous calendar year.
6.32The withheld funds must be returned no sooner than July 1 and no later than July 31
6.33of the following calendar year if the managed care plan demonstrates to the satisfaction of
6.34the commissioner thata this reduction in the utilization rate was achieved.
6.35The withhold described in this paragraph shall continue for each consecutive
6.36contract period until the plan's emergency room utilization rate for state health care
7.1program enrollees is reduced by 25 percent of the plan's emergency room utilization
7.2rate for state health care program enrollees for calendar year 2009. Hospitals shall
7.3cooperate with the health plans in meeting this performance target and shall accept
7.4payment withholds that may be returned to the hospitals if the performance target is
7.5achieved.The commissioner shall structure the withhold so that the commissioner returns
7.6a portion of the withheld funds in amounts commensurate with achieved reductions in
7.7utilization less than the targeted amount. The withhold in this paragraph does not apply to
7.8county-based purchasing plans.
7.9(h) Effective for services rendered on or after January 1, 2012, the commissioner
7.10shall include as part of the performance targets described in paragraph (c) a reduction in
7.11the plan's hospitalization admission rate for hospitalizations for state health care program
7.12enrollees by a measurable rate of five percent from the plan's utilization rate for state
7.13health care program enrollees for the previous calendar year.
7.14The withheld funds must be returned no sooner than July 1 and no later than July
7.1531 of the following calendar year if the managed care plan or county-based purchasing
7.16plan demonstrates to the satisfaction of the commissioner that this reduction in the
7.17hospitalization rate was achieved.
7.18The withhold described in this paragraph shall continue for three consecutive
7.19contract periods. Hospitals shall cooperate with the plans in meeting this performance
7.20target and shall accept payment withholds that may be returned to the hospitals if the
7.21performance target is achieved.
7.22(h) (i) Effective for services rendered on or after January 1, 2011, through December
7.2331, 2011, the commissioner shall withhold 4.5 percent of managed care plan payments
7.24under this section and county-based purchasing plan payments under section256B.692
7.25for the prepaid medical assistance program. The withheld funds must be returned no
7.26sooner than July 1 and no later than July 31 of the following year. The commissioner may
7.27exclude special demonstration projects under subdivision 23.
7.28(i) (j) Effective for services rendered on or after January 1, 2012, through December
7.2931, 2012, the commissioner shall withhold 4.5 percent of managed care plan payments
7.30under this section and county-based purchasing plan payments under section256B.692
7.31for the prepaid medical assistance program. The withheld funds must be returned no
7.32sooner than July 1 and no later than July 31 of the following year. The commissioner may
7.33exclude special demonstration projects under subdivision 23.
7.34(j) (k) Effective for services rendered on or after January 1, 2013, through December
7.3531, 2013, the commissioner shall withhold 4.5 percent of managed care plan payments
7.36under this section and county-based purchasing plan payments under section256B.692
8.1for the prepaid medical assistance program. The withheld funds must be returned no
8.2sooner than July 1 and no later than July 31 of the following year. The commissioner may
8.3exclude special demonstration projects under subdivision 23.
8.4(k) (l) Effective for services rendered on or after January 1, 2014, the commissioner
8.5shall withhold three percent of managed care plan payments under this section and
8.6county-based purchasing plan payments under section256B.692 for the prepaid medical
8.7assistance program. The withheld funds must be returned no sooner than July 1 and
8.8no later than July 31 of the following year. The commissioner may exclude special
8.9demonstration projects under subdivision 23.
8.10(l) (m) A managed care plan or a county-based purchasing plan under section
8.11256B.692
may include as admitted assets under section
62D.044 any amount withheld
8.12under this section that is reasonably expected to be returned.
8.13(m) (n) Contracts between the commissioner and a prepaid health plan are exempt
8.14from the set-aside and preference provisions of section16C.16, subdivisions 6 , paragraph
8.15(a), and 7.
8.16(n) (o) The return of the withhold under paragraphs (d), (f), and (h) to (k) is not
8.17subject to the requirements of paragraph (c).
8.18 Sec. 5. Minnesota Statutes 2010, section 256B.69, subdivision 5i, is amended to read:
8.19 Subd. 5i. Administrative expenses. (a) Managed care plan and county-based
8.20purchasing plan administrative costs for a prepaid health plan provided under this section
8.21or section256B.692 must not exceed by more than five percent that prepaid health plan's
8.22or county-based purchasing plan's actual calculated administrative spending for the
8.23previous calendar year as a percentage of total revenue. The penalty for exceeding this
8.24limit must be the amount of administrative spending in excess of 105 percent of the actual
8.25calculated amount. The commissioner may waive this penalty if the excess administrative
8.26spending is the result of unexpected shifts in enrollment or member needs or new program
8.27requirements.
8.28 (b) Expenses listed under section62D.12, subdivision 9a , clause (4), are not
8.29allowable administrative expenses for rate-setting purposes under this section, unless
8.30approved by the commissioner.
8.31(c) Notwithstanding paragraph (a), the portion of the per member per month
8.32capitation rate paid under this section to managed care plans and county-based purchasing
8.33plans for administrative expenditures shall be reduced by 21 cents beginning July 1, 2011.
8.34 Sec. 6. Minnesota Statutes 2010, section 256B.69, subdivision 28, is amended to read:
9.1 Subd. 28. Medicare special needs plans; medical assistance basic health care.
9.2 (a) The commissioner may contract with qualified Medicare-approved special needs
9.3plans to provide medical assistance basic health care services to persons with disabilities,
9.4including those with developmental disabilities. Basic health care services include:
9.5 (1) those services covered by the medical assistance state plan except for ICF/MR
9.6services, home and community-based waiver services, case management for persons with
9.7developmental disabilities under section256B.0625 , subdivision 20a, and personal care
9.8and certain home care services defined by the commissioner in consultation with the
9.9stakeholder group established under paragraph (d); and
9.10 (2) basic health care services may also include risk for up to 100 days of nursing
9.11facility services for persons who reside in a noninstitutional setting and home health
9.12services related to rehabilitation as defined by the commissioner after consultation with
9.13the stakeholder group.
9.14 The commissioner may exclude other medical assistance services from the basic
9.15health care benefit set. Enrollees in these plans can access any excluded services on the
9.16same basis as other medical assistance recipients who have not enrolled.
9.17Unless a person is otherwise required to enroll in managed care, enrollment in these
9.18plans for Medicaid services must be voluntary. For purposes of this subdivision, automatic
9.19enrollment with an option to opt out is not voluntary enrollment.
9.20 (b) Beginning January 1, 2007, the commissioner may contract with qualified
9.21Medicare special needs plans to provide basic health care services under medical
9.22assistance to persons who are dually eligible for both Medicare and Medicaid and those
9.23Social Security beneficiaries eligible for Medicaid but in the waiting period for Medicare.
9.24The commissioner shall consult with the stakeholder group under paragraph (d) in
9.25developing program specifications for these services. The commissioner shall report to
9.26the chairs of the house of representatives and senate committees with jurisdiction over
9.27health and human services policy and finance by February 1, 2007, on implementation
9.28of these programs and the need for increased funding for the ombudsman for managed
9.29care and other consumer assistance and protections needed due to enrollment in managed
9.30care of persons with disabilities. Payment for Medicaid services provided under this
9.31subdivision for the months of May and June will be made no earlier than July 1 of the
9.32same calendar year.
9.33 (c) Notwithstanding subdivision 4, beginning January 1,2008 2012, the
9.34commissionermay expand contracting under this subdivision to all shall enroll persons
9.35with disabilitiesnot otherwise required to enroll in managed care under this section,
9.36unless the individual chooses to opt-out of enrollment. The commissioner shall establish
10.1enrollment and opt out procedures consistent with applicable enrollment procedures under
10.2this subdivision.
10.3 (d) The commissioner shall establish a state-level stakeholder group to provide
10.4advice on managed care programs for persons with disabilities, including both MnDHO
10.5and contracts with special needs plans that provide basic health care services as described
10.6in paragraphs (a) and (b). The stakeholder group shall provide advice on program
10.7expansions under this subdivision and subdivision 23, including:
10.8 (1) implementation efforts;
10.9 (2) consumer protections; and
10.10 (3) program specifications such as quality assurance measures, data collection and
10.11reporting, and evaluation of costs, quality, and results.
10.12 (e) Each plan under contract to provide medical assistance basic health care services
10.13shall establish a local or regional stakeholder group, including representatives of the
10.14counties covered by the plan, members, consumer advocates, and providers, for advice on
10.15issues that arise in the local or regional area.
10.16 (f) The commissioner is prohibited from providing the names of potential enrollees
10.17to health plans for marketing purposes. The commissioner may mail marketing materials
10.18to potential enrollees on behalf of health plans, in which case the health plans shall cover
10.19any costs incurred by the commissioner for mailing marketing materials.
10.20 Sec. 7. Minnesota Statutes 2010, section 256L.12, subdivision 9, is amended to read:
10.21 Subd. 9. Rate setting; performance withholds. (a) Rates will be prospective,
10.22per capita, where possible. The commissioner may allow health plans to arrange for
10.23inpatient hospital services on a risk or nonrisk basis. The commissioner shall consult with
10.24an independent actuary to determine appropriate rates.
10.25 (b) For services rendered on or after January 1, 2004, the commissioner shall
10.26withhold five percent of managed care plan payments and county-based purchasing
10.27plan payments under this section pending completion of performance targets. Each
10.28performance target must be quantifiable, objective, measurable, and reasonably attainable,
10.29except in the case of a performance target based on a federal or state law or rule. Criteria
10.30for assessment of each performance target must be outlined in writing prior to the
10.31contract effective date. The managed care plan must demonstrate, to the commissioner's
10.32satisfaction, that the data submitted regarding attainment of the performance target is
10.33accurate. The commissioner shall periodically change the administrative measures used
10.34as performance targets in order to improve plan performance across a broader range of
10.35administrative services. The performance targets must include measurement of plan
11.1efforts to contain spending on health care services and administrative activities. The
11.2commissioner may adopt plan-specific performance targets that take into account factors
11.3affecting only one plan, such as characteristics of the plan's enrollee population. The
11.4withheld funds must be returned no sooner than July 1 and no later than July 31 of the
11.5following calendar year if performance targets in the contract are achieved.
11.6(c) For services rendered on or after January 1, 2011, the commissioner shall
11.7withhold an additional three percent of managed care plan or county-based purchasing
11.8plan payments under this section. The withheld funds must be returned no sooner than
11.9July 1 and no later than July 31 of the following calendar year. The return of the withhold
11.10under this paragraph is not subject to the requirements of paragraph (b).
11.11(d) Effective for services rendered on or after January 1, 2011, through December
11.1231, 2011, the commissioner shall include as part of the performance targets described in
11.13paragraph (b) a reduction in the plan's emergency room utilization rate for state health
11.14care program enrollees by a measurable rate of five percent from the plan's utilization
11.15rate for the previous calendar year. Effective for services rendered on or after January
11.161, 2012, the commissioner shall include as part of the performance targets described in
11.17paragraph (b) a reduction in the plan's emergency room utilization rate for state health
11.18care program enrollees by a measurable rate of ten percent from the plan's utilization
11.19rate for the previous calendar year.
11.20The withheld funds must be returned no sooner than July 1 and no later than July 31
11.21of the following calendar year if the managed care plan demonstrates to the satisfaction of
11.22the commissioner thata this reduction in the utilization rate was achieved.
11.23The withhold described in this paragraph shall continue for each consecutive
11.24contract period until the plan's emergency room utilization rate for state health care
11.25program enrollees is reduced by 25 percent of the plan's emergency room utilization rate
11.26for state health care program enrollees for calendar year 2009. Hospitals shall cooperate
11.27with the health plans in meeting this performance target and shall accept payment
11.28withholds that may be returned to the hospitals if the performance target is achieved.
11.29The commissioner shall structure the withhold so that the commissioner returns a portion
11.30of the withheld funds in amounts commensurate with achieved reductions in utilization
11.31less than the targeted amount. The withhold described in this paragraph does not apply to
11.32county-based purchasing plans.
11.33(e) Effective for services rendered on or after January 1, 2012, the commissioner
11.34shall include as part of the performance targets described in paragraph (b) a reduction
11.35in the plan's hospitalization admission rate for state health care program enrollees by
12.1a measurable rate of five percent from the plan's hospitalization rate for the previous
12.2calendar year.
12.3The withheld funds must be returned no sooner than July 1 and no later than July
12.431 of the following calendar year if the managed care plan or county-based purchasing
12.5plan demonstrates to the satisfaction of the commissioner that this reduction in the
12.6hospitalization rate was achieved.
12.7The withhold described in this paragraph shall continue for three consecutive
12.8contract periods. Hospitals shall cooperate with the plans in meeting this performance
12.9target and shall accept payment withholds that may be returned to the hospitals if the
12.10performance target is achieved.
12.11(e) (f) A managed care plan or a county-based purchasing plan under section
12.12256B.692
may include as admitted assets under section
62D.044 any amount withheld
12.13under this section that is reasonably expected to be returned.
12.14 Sec. 8. Laws 2009, chapter 79, article 13, section 3, subdivision 8, as amended by
12.15Laws 2009, chapter 173, article 2, section 1, subdivision 8, Laws 2010, First Special
12.16Session chapter 1, article 15, section 5, and Laws 2010, First Special Session chapter 1,
12.17article 25, section 16, is amended to read:
12.19The amounts that may be spent from the
12.20appropriation for each purpose are as follows:
12.22Base Adjustment. The general fund base is
12.23increased by $5,751,000 in fiscal year 2012
12.24and $6,705,000 in fiscal year 2013.
12.25Information and Assistance
12.26Reimbursement. Federal administrative
12.27reimbursement obtained from information
12.28and assistance services provided by the
12.29Senior LinkAge or Disability Linkage lines
12.30to people who are identified as eligible for
12.31medical assistance shall be appropriated to
12.32the commissioner for this activity.
12.33Community Service Development Grant
12.34Reduction. Funding for community service
13.1development grants must be reduced by
13.2$260,000 for fiscal year 2010; $284,000 in
13.3fiscal year 2011; $43,000 in fiscal year 2012;
13.4and $43,000 in fiscal year 2013. Base level
13.5funding shall be restored in fiscal year 2014.
13.6Community Service Development Grant
13.7Community Initiative. Funding for
13.8community service development grants shall
13.9be used to offset the cost of aging support
13.10grants. Base level funding shall be restored
13.11in fiscal year 2014.
13.12Senior Nutrition Use of Federal Funds.
13.13For fiscal year 2010, general fund grants
13.14for home-delivered meals and congregate
13.15dining shall be reduced by $500,000. The
13.16commissioner must replace these general
13.17fund reductions with equal amounts from
13.18federal funding for senior nutrition from the
13.19American Recovery and Reinvestment Act
13.20of 2009.
13.22Base Adjustment. The general fund base is
13.23decreased by $3,598,000 in fiscal year 2012
13.24and $3,470,000 in fiscal year 2013.
13.25Alternative Care Transfer. Any money
13.26allocated to the alternative care program that
13.27is not spent for the purposes indicated does
13.28not cancel but must be transferred to the
13.29medical assistance account.
13.34Manage Growth in TBI and CADI
13.35Waivers. During the fiscal years beginning
14.1on July 1, 2009, and July 1, 2010, the
14.2commissioner shall allocate money for home
14.3and community-based waiver programs
14.4under Minnesota Statutes, section256B.49 ,
14.5to ensure a reduction in state spending that is
14.6equivalent to limiting the caseload growth of
14.7the TBI waiver to 12.5 allocations per month
14.8each year of the biennium and the CADI
14.9waiver to 95 allocations per month each year
14.10of the biennium. Limits do not apply: (1)
14.11when there is an approved plan for nursing
14.12facility bed closures for individuals under
14.13age 65 who require relocation due to the
14.14bed closure; (2) to fiscal year 2009 waiver
14.15allocations delayed due to unallotment; or (3)
14.16to transfers authorized by the commissioner
14.17from the personal care assistance program
14.18of individuals having a home care rating
14.19of "CS," "MT," or "HL." Priorities for the
14.20allocation of funds must be for individuals
14.21anticipated to be discharged from institutional
14.22settings or who are at imminent risk of a
14.23placement in an institutional setting.
14.24Manage Growth in DD Waiver. The
14.25commissioner shall manage the growth in
14.26the DD waiver by limiting the allocations
14.27included in the February 2009 forecast to 15
14.28additional diversion allocations each month
14.29for the calendar years that begin on January
14.301, 2010, and January 1, 2011. Additional
14.31allocations must be made available for
14.32transfers authorized by the commissioner
14.33from the personal care program of individuals
14.34having a home care rating of "CS," "MT,"
14.35or "HL."
15.1Adjustment to Lead Agency Waiver
15.2Allocations. Prior to the availability of the
15.3alternative license defined in Minnesota
15.4Statutes, section245A.11, subdivision 8 ,
15.5the commissioner shall reduce lead agency
15.6waiver allocations for the purposes of
15.7implementing a moratorium on corporate
15.8foster care.
15.9Alternatives to Personal Care Assistance
15.10Services. Base level funding of $3,237,000
15.11in fiscal year 2012 and $4,856,000 in
15.12fiscal year 2013 is to implement alternative
15.13services to personal care assistance services
15.14for persons with mental health and other
15.15behavioral challenges who can benefit
15.16from other services that more appropriately
15.17meet their needs and assist them in living
15.18independently in the community. These
15.19services may include, but not be limited to, a
15.201915(i) state plan option.
15.26Funding Usage. Up to 75 percent of a fiscal
15.27year's appropriation for adult mental health
15.28grants may be used to fund allocations in that
15.29portion of the fiscal year ending December
15.3031.
15.33Payments for Substance Abuse Treatment.
15.34For placements beginning during fiscal years
15.352010 and 2011, county-negotiated rates and
16.1provider claims to the consolidated chemical
16.2dependency fund must not exceed the lesser
16.3of:
16.4(1) rates charged for these services on
16.5January 1, 2009;and or
16.6(2) 160 percent of the average rate on January
16.71, 2009, for each group of vendors with
16.8similar attributes.
16.9Rates for fiscal years 2010 and 2011 must
16.10not exceed 160 percent of the average rate on
16.11January 1, 2009, for each group of vendors
16.12with similar attributes.
16.13Effective July 1, 2010, rates that were above
16.14the average rate on January 1, 2009, are
16.15reduced by five percent from the rates in
16.16effect on June 1, 2010. Rates below the
16.17average rate on January 1, 2009, are reduced
16.18by 1.8 percent from the rates in effect on
16.19June 1, 2010. Services provided under
16.20this section by state-operated services are
16.21exempt from the rate reduction. For services
16.22provided in fiscal years 2012 and 2013, the
16.23statewide aggregate payment under the new
16.24rate methodology to be developed under
16.25Minnesota Statutes, section254B.12 , must
16.26not exceed the projected aggregate payment
16.27under the rates in effect for fiscal year 2011
16.28excluding the rate reduction for rates that
16.29were below the average on January 1, 2009,
16.30plus a state share increase of $3,787,000 for
16.31fiscal year 2012 and $5,023,000 for fiscal
16.32year 2013. Notwithstanding any provision
16.33to the contrary in this article, this provision
16.34expires on June 30, 2013.
17.1Chemical Dependency Special Revenue
17.2Account. For fiscal year 2010, $750,000
17.3must be transferred from the consolidated
17.4chemical dependency treatment fund
17.5administrative account and deposited into the
17.6general fund.
17.7County CD Share of MA Costs for
17.8ARRA Compliance. Notwithstanding the
17.9provisions of Minnesota Statutes, chapter
17.10254B, for chemical dependency services
17.11provided during the period October 1, 2008,
17.12to December 31, 2010, and reimbursed by
17.13medical assistance at the enhanced federal
17.14matching rate provided under the American
17.15Recovery and Reinvestment Act of 2009, the
17.16county share is 30 percent of the nonfederal
17.17share. This provision is effective the day
17.18following final enactment.
17.22Base Adjustment. The general fund base is
17.23increased by $2,639,000 in fiscal year 2012
17.24and increased by $3,854,000 in fiscal year
17.252013.
17.26Technology Grants. $650,000 in fiscal
17.27year 2010 and $1,000,000 in fiscal year
17.282011 are for technology grants, case
17.29consultation, evaluation, and consumer
17.30information grants related to developing and
17.31supporting alternatives to shift-staff foster
17.32care residential service models.
17.33Other Continuing Care Grants; HIV
17.34Grants. Money appropriated for the HIV
17.35drug and insurance grant program in fiscal
18.1year 2010 may be used in either year of the
18.2biennium.
18.3Quality Assurance Commission. Effective
18.4July 1, 2009, state funding for the quality
18.5assurance commission under Minnesota
18.6Statutes, section256B.0951 , is canceled.
18.7 Sec. 9. CAPITATION PAYMENT DELAY.
18.8(a) The commissioner of human services shall delay the MinnesotaCare capitation
18.9payment due in May of 2013 to managed care plans for single adults without children
18.10eligible under Minnesota Statutes, section 256L.04, subdivision 7, until July of 2013.
18.11(b) The commissioner of human services shall delay payments due in April of 2013
18.12for medical assistance services provided under Minnesota Statutes, section 256B.69,
18.13subdivision 28, until after July 1, 2013.
18.14 Sec. 10. HEALTH CARE DELIVERY SYSTEMS DEMONSTRATION
18.15PROJECT.
18.16 Subdivision 1. Implementation. (a) The commissioner shall develop and authorize
18.17a demonstration project to test alternative and innovative health care delivery systems,
18.18including accountable care organizations that provide services to a specified patient
18.19population for an agreed-upon total cost of care payment arrangement in accordance with
18.20subdivision 4. The commissioner shall develop one request for proposals to provide
18.21services to the elderly population eligible for medical assistance, and one request for
18.22proposals to provide services to families and children eligible for medical assistance
18.23and the MinnesotaCare program.
18.24(b) In developing the request for proposals, the commissioner shall:
18.25(1) establish uniform statewide methods of forecasting utilization and cost of care
18.26for the specified populations, to be used by the commissioner for the health care delivery
18.27system projects;
18.28(2) identify key indicators of quality, access, patient satisfaction, and other
18.29performance indicators that will be measured, in addition to indicators for measuring
18.30cost savings;
18.31(3) allow maximum flexibility to encourage innovation and variation so that a variety
18.32of provider collaborations are able to become health care delivery systems; and
18.33(4) establish quality standards for the delivery system demonstrations.
19.1(c) To be eligible to participate in the demonstration project, a health care delivery
19.2system must:
19.3(1) provide required covered services and care coordination to recipients enrolled in
19.4the demonstration project;
19.5(2) establish a process to ensure the quality of care provided;
19.6(3) in cooperation with counties and community social service agencies, coordinate
19.7the delivery of health care services with existing social services programs;
19.8(4) provide a system for advocacy and consumer protection; and
19.9(5) adopt innovative and cost-effective methods of care delivery and coordination,
19.10which may include the use of allied health professionals, telemedicine, patient educators,
19.11care coordinators, and community health workers.
19.12(d) A health care delivery system demonstration may be formed by the following
19.13groups of providers of services and suppliers if they have established a mechanism for
19.14shared governance:
19.15(1) professionals in group practice arrangements;
19.16(2) networks of individual practices of professionals;
19.17(3) partnerships or joint venture arrangements between hospitals and health care
19.18professionals;
19.19(4) hospitals employing professionals; and
19.20(5) other groups of providers of services and suppliers as the commissioner
19.21determines appropriate.
19.22A managed care plan or county-based purchasing plan may participate in this
19.23demonstration in collaboration with one or more of the entities listed in clauses (1) to (5).
19.24A health care delivery system may contract with a managed care plan or a
19.25county-based purchasing plan to provide administrative services, including the
19.26administration of a payment system using the payment methods approved by the
19.27commissioner for health care delivery systems.
19.28(e) The commissioner may require a health care delivery system to enter into
19.29additional third-party contractual relationships for the assessment of risk and purchase of
19.30stop loss insurance or another form of insurance risk management related to the delivery
19.31of care described in paragraph (c).
19.32 Subd. 2. Enrollment. (a) The commissioner shall develop and authorize at least
19.33two demonstration projects: one for families and children eligible for medical assistance
19.34and MinnesotaCare; and one for individuals 65 years of age or older eligible for medical
19.35assistance.
20.1(b) Eligible applicants and recipients shall enroll in a health care delivery system
20.2if a system serves the county in which the applicant or recipient resides. If more than
20.3one health care delivery system serves a county, the applicant or recipient may choose
20.4among the delivery systems. The commissioner shall assign an applicant or recipient to a
20.5health care delivery system if a health care delivery system is available and no choice has
20.6been made by the applicant or recipient.
20.7 Subd. 3. Accountability. (a) Health care delivery systems must accept responsibility
20.8for the quality of care based on standards established under subdivision 1, paragraph (b),
20.9clause (4), and the cost of care or utilization of services provided to its enrollees under
20.10subdivision 1, paragraph (b), clause (1).
20.11(b) A health care delivery system may contract and coordinate with providers and
20.12clinics for the delivery of services and shall contract with community health clinics,
20.13federally qualified health centers, community mental health centers or programs, and rural
20.14clinics to the extent practicable.
20.15 Subd. 4. Payment system. (a) In developing a payment system for health care
20.16delivery systems, the commissioner shall establish a total cost of care benchmark to be
20.17paid for services provided to the recipients enrolled in a health care delivery system.
20.18(b) The total cost of care payment system shall not exceed the payments made
20.19in fiscal year 2011 by the commissioner under fee-for-service or managed care for the
20.20delivery of services to the specified populations within the geographic area served by the
20.21health care delivery system minus five percent.
20.22(c) The payment system developed under this section shall incorporate the withhold
20.23and performance target requirements in Minnesota Statutes, section 256B.69, subdivision
20.245a.
20.25 Sec. 11. MANAGE GROWTH IN TRAUMATIC BRAIN INJURY AND
20.26COMMUNITY ALTERNATIVES FOR DISABLED INDIVIDUALS WAIVERS.
20.27During the fiscal years beginning July 1, 2011, and July 1, 2012, the commissioner
20.28shall allocate money for home and community-based waiver programs under Minnesota
20.29Statutes, section256B.49 , to ensure a reduction in state spending that is equivalent to
20.30limiting the caseload growth of the traumatic brain injury waiver to six allocations per
20.31month each year of the biennium and the community alternatives for disabled individuals
20.32waiver to 60 allocations per month. The limits do not apply:
20.33(1) when there is an approved plan for nursing facility bed closures for individuals
20.34under age 65 who require relocation due to the bed closure;
20.35(2) to fiscal year 2009 waiver allocations delayed due to unallotment; or
21.1(3) to transfers authorized by the commissioner from the personal care assistance
21.2program of individuals having a home care rating of CS, MT, or HL. Priorities for the
21.3allocation of funds must be for individuals anticipated to be discharged from institutional
21.4settings or who are at imminent risk of a placement in an institutional setting.
21.5 Sec. 12. MANAGE GROWTH IN DEVELOPMENTAL DISABILITY (DD)
21.6WAIVER.
21.7The commissioner shall manage the growth in the developmental disability waiver
21.8by limiting the allocations included in the November 2010 forecast to six additional
21.9diversion allocations each month for the fiscal year that begins on July 1, 2011. Additional
21.10allocations must be made available for transfers authorized by the commissioner from the
21.11personal care assistance program of individuals having a home care rating of CS, MT,
21.12or HL. This provision is effective through June 30, 2013.
21.13 Sec. 13. REQUEST FOR PROPOSALS; CLAIMS PROCESSING FOR
21.14FEE-FOR-SERVICE MEDICAL ASSISTANCE.
21.15(a) The commissioner of human services shall issue a request for proposal for a
21.16contract to provide claims processing services for the fee-for-service medical assistance
21.17program, excluding outpatient pharmacy services. The contractor must be able to:
21.18(1) process provider claims in a timely manner and within state and federal
21.19requirements;
21.20(2) provide electronic claims submission access for providers;
21.21(3) validate claims data;
21.22(4) file and reconcile claims;
21.23(5) identify fraud and abuse;
21.24(6) measure quality assurance and performance outcomes; and
21.25(7) coordinate benefits on the front end of a claim.
21.26(b) The commissioner shall enter into a contract for claims processing by January 1,
21.272012. Payment under the contract shall not exceed $1.75 on average per claim processed.
21.28(c) The commissioner shall apply for any federal grants that may be available.
21.29EFFECTIVE DATE.This section is effective the day following final enactment.
1.3plans and county-based purchasing plans under the medical assistance program
1.4and the administrative payments to third-party administrators that administer
1.5the state employee group insurance plan; modifying personal care assistance
1.6services; creating a withhold to managed care plans and county-based purchasing
1.7plans for reducing hospitalizations; modifying the emergency room utilization
1.8rate withhold to managed care plans; delaying capitation payments for single
1.9adults without children in MinnesotaCare; creating demonstration projects for
1.10the delivery of health care services to certain medical assistance populations;
1.11limiting home and community-based waiver services allocations; requiring the
1.12commissioner of human services to issue a request for proposals to provide
1.13claims processing services for the fee-for-service medical assistance program;
1.14amending Minnesota Statutes 2010, sections 43A.23, subdivision 1; 256B.0625,
1.15subdivision 19a; 256B.0652, subdivision 6; 256B.69, subdivisions 5a, 5i, 28;
1.16256L.12, subdivision 9; Laws 2009, chapter 79, article 13, section 3, subdivision
1.178, as amended.
1.18BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.19 Section 1. Minnesota Statutes 2010, section 43A.23, subdivision 1, is amended to read:
1.20 Subdivision 1. General. (a) The commissioner is authorized to request proposals
1.21or to negotiate and to enter into contracts with parties which in the judgment of the
1.22commissioner are best qualified to provide service to the benefit plans. Contracts entered
1.23into are not subject to the requirements of sections
1.24may negotiate premium rates and coverage. The commissioner shall consider the cost of
1.25the plans, conversion options relating to the contracts, service capabilities, character,
1.26financial position, and reputation of the carriers, and any other factors which the
1.27commissioner deems appropriate. Each benefit contract must be for a uniform term of at
1.28least one year, but may be made automatically renewable from term to term in the absence
2.1of notice of termination by either party. A carrier licensed under chapter 62A is exempt
2.2from the taxes imposed by chapter 297I on premiums paid to it by the state.
2.3 (b) All self-insured hospital and medical service products must comply with coverage
2.4mandates, data reporting, and consumer protection requirements applicable to the licensed
2.5carrier administering the product, had the product been insured, including chapters 62J,
2.662M, and 62Q. Any self-insured products that limit coverage to a network of providers
2.7or provide different levels of coverage between network and nonnetwork providers shall
2.8comply with section
2.9organizations adopted by the commissioner of health in rule under chapter 62D.
2.10 (c) Notwithstanding paragraph (b), a self-insured hospital and medical product
2.11offered under sections
2.12an eligible employee's unmarried child under the age of 25 to the full extent required under
2.13chapters 62A and 62L. Dependent coverage must, at a minimum, extend to an eligible
2.14employee's unmarried child who is under the age of 19 or an unmarried child under the
2.15age of 25 who is a full-time student. A person who is at least 19 years of age but who is
2.16under the age of 25 and who is not a full-time student must be permitted to be enrolled as
2.17a dependent of an eligible employee until age 25 if the person:
2.18(1) was a full-time student immediately prior to being ordered into active military
2.19service, as defined in section
2.20(2) has been separated or discharged from active military service; and
2.21(3) would be eligible to enroll as a dependent of an eligible employee, except that
2.22the person is not a full-time student.
2.23The definition of "full-time student" for purposes of this paragraph includes any student
2.24who by reason of illness, injury, or physical or mental disability as documented by
2.25a physician is unable to carry what the educational institution considers a full-time
2.26course load so long as the student's course load is at least 60 percent of what otherwise
2.27is considered by the institution to be a full-time course load. Any notice regarding
2.28termination of coverage due to attainment of the limiting age must include information
2.29about this definition of "full-time student."
2.30 (d) Beginning January 1, 2010, the health insurance benefit plans offered in the
2.31commissioner's plan under section
2.32section
2.33with the definition of a high-deductible health plan in section 223 of the United States
2.34Internal Revenue Code.
2.35(e) Beginning January 1, 2011, any contract entered into by the commissioner with
2.36a licensed carrier or third-party administrator to administer the health insurance benefit
3.1plans offered under sections 43A.22 to 43A.30 shall reflect a reduction in administrative
3.2costs that equals a per enrollee per month reduction of 21 cents.
3.3 Sec. 2. Minnesota Statutes 2010, section 256B.0625, subdivision 19a, is amended to
3.4read:
3.5 Subd. 19a. Personal care assistance services. Medical assistance covers personal
3.6care assistance services in a recipient's home. Effective January 1, 2010, to qualify for
3.7personal care assistance services, a recipient must require assistance and be determined
3.8dependent in one activity of daily living as defined in section
3.9paragraph (b), or in a Level I behavior as defined in section
3.10paragraph (c).
3.11
3.12
3.13be able to identify the recipient's needs, direct and evaluate task accomplishment, and
3.14provide for health and safety. Approved hours may be used outside the home when normal
3.15life activities take them outside the home. To use personal care assistance services at
3.16school, the recipient or responsible party must provide written authorization in the care
3.17plan identifying the chosen provider and the daily amount of services to be used at school.
3.18Total hours for services, whether actually performed inside or outside the recipient's
3.19home, cannot exceed that which is otherwise allowed for personal care assistance services
3.20in an in-home setting according to sections
3.21does not cover personal care assistance services for residents of a hospital, nursing facility,
3.22intermediate care facility, health care facility licensed by the commissioner of health, or
3.23unless a resident who is otherwise eligible is on leave from the facility and the facility
3.24either pays for the personal care assistance services or forgoes the facility per diem for the
3.25leave days that personal care assistance services are used. All personal care assistance
3.26services must be provided according to sections
3.27assistance services may not be reimbursed if the personal care assistant is the spouse or
3.28paid guardian of the recipient or the parent of a recipient under age 18, or the responsible
3.29party or the family foster care provider of a recipient who cannot direct the recipient's own
3.30care unless, in the case of a foster care provider, a county or state case manager visits
3.31the recipient as needed, but not less than every six months, to monitor the health and
3.32safety of the recipient and to ensure the goals of the care plan are met. Notwithstanding
3.33the provisions of section
3.34who is not the responsible party and not the personal care provider organization, may be
3.35reimbursed to provide personal care assistance services to the recipient if the guardian or
4.1conservator meets all criteria for a personal care assistant according to section
4.2and shall not be considered to have a service provider interest for purposes of participation
4.3on the screening team under section
4.4 Sec. 3. Minnesota Statutes 2010, section 256B.0652, subdivision 6, is amended to read:
4.5 Subd. 6. Authorization; personal care assistance and qualified professional.
4.6 (a) All personal care assistance services, supervision by a qualified professional, and
4.7additional services beyond the limits established in subdivision 11, must be authorized
4.8by the commissioner or the commissioner's designee before services begin except for the
4.9assessments established in subdivision 11 and section
4.10personal care assistance and qualified professional services under section
4.11be completed within 30 days after receiving a complete request.
4.12 (b) The amount of personal care assistance services authorized must be based
4.13on the recipient's home care rating. The home care rating shall be determined by the
4.14commissioner or the commissioner's designee based on information submitted to the
4.15commissioner identifying the following for recipients with dependencies in two or more
4.16activities of daily living:
4.17 (1) total number of dependencies of activities of daily living as defined in section
4.19 (2) presence of complex health-related needs as defined in section
4.20 (3) presence of Level I behavior as defined in section
4.21 (c) For persons meeting the criteria in paragraph (b), the methodology to determine
4.22total time for personal care assistance services for each home care rating is based on
4.23the median paid units per day for each home care rating from fiscal year 2007 data for
4.24the personal care assistance program. Each home care rating has a base level of hours
4.25assigned. Additional time is added through the assessment and identification of the
4.26following:
4.27 (1) 30 additional minutes per day for a dependency in each critical activity of daily
4.28living as defined in section
4.29 (2) 30 additional minutes per day for each complex health-related function as
4.30defined in section
4.31 (3) 30 additional minutes per day for each behavior issue as defined in section
4.33 (d) Effective July 1, 2011, the home care rating for recipients who have a dependency
4.34in one activity of daily living or level one behavior shall equal no more than two units per
5.1day. Recipients with this home care rating are not subject to the methodology in paragraph
5.2(c), and are not eligible for more than two units per day.
5.3(e) A limit of 96 units of qualified professional supervision may be authorized for
5.4each recipient receiving personal care assistance services. A request to the commissioner
5.5to exceed this total in a calendar year must be requested by the personal care provider
5.6agency on a form approved by the commissioner.
5.7 Sec. 4. Minnesota Statutes 2010, section 256B.69, subdivision 5a, is amended to read:
5.8 Subd. 5a. Managed care contracts. (a) Managed care contracts under this section
5.9and section
5.10January 1, 1996. Managed care contracts which were in effect on June 30, 1995, and set to
5.11renew on July 1, 1995, shall be renewed for the period July 1, 1995 through December
5.1231, 1995 at the same terms that were in effect on June 30, 1995. The commissioner may
5.13issue separate contracts with requirements specific to services to medical assistance
5.14recipients age 65 and older.
5.15 (b) A prepaid health plan providing covered health services for eligible persons
5.16pursuant to chapters 256B and 256L is responsible for complying with the terms of its
5.17contract with the commissioner. Requirements applicable to managed care programs
5.18under chapters 256B and 256L established after the effective date of a contract with the
5.19commissioner take effect when the contract is next issued or renewed.
5.20 (c) Effective for services rendered on or after January 1, 2003, the commissioner
5.21shall withhold five percent of managed care plan payments under this section and
5.22county-based purchasing plan payments under section
5.23assistance program pending completion of performance targets. Each performance target
5.24must be quantifiable, objective, measurable, and reasonably attainable, except in the case
5.25of a performance target based on a federal or state law or rule. Criteria for assessment
5.26of each performance target must be outlined in writing prior to the contract effective
5.27date. The managed care plan must demonstrate, to the commissioner's satisfaction,
5.28that the data submitted regarding attainment of the performance target is accurate. The
5.29commissioner shall periodically change the administrative measures used as performance
5.30targets in order to improve plan performance across a broader range of administrative
5.31services. The performance targets must include measurement of plan efforts to contain
5.32spending on health care services and administrative activities. The commissioner may
5.33adopt plan-specific performance targets that take into account factors affecting only one
5.34plan, including characteristics of the plan's enrollee population. The withheld funds
5.35must be returned no sooner than July of the following year if performance targets in the
6.1contract are achieved. The commissioner may exclude special demonstration projects
6.2under subdivision 23.
6.3 (d) Effective for services rendered on or after January 1, 2009, through December
6.431, 2009, the commissioner shall withhold three percent of managed care plan payments
6.5under this section and county-based purchasing plan payments under section
6.7sooner than July 1 and no later than July 31 of the following year. The commissioner may
6.8exclude special demonstration projects under subdivision 23.
6.9(e) Effective for services provided on or after January 1, 2010, the commissioner
6.10shall require that managed care plans use the assessment and authorization processes,
6.11forms, timelines, standards, documentation, and data reporting requirements, protocols,
6.12billing processes, and policies consistent with medical assistance fee-for-service or the
6.13Department of Human Services contract requirements consistent with medical assistance
6.14fee-for-service or the Department of Human Services contract requirements for all
6.15personal care assistance services under section
6.16(f) Effective for services rendered on or after January 1, 2010, through December
6.1731, 2010, the commissioner shall withhold 4.5 percent of managed care plan payments
6.18under this section and county-based purchasing plan payments under section
6.20sooner than July 1 and no later than July 31 of the following year. The commissioner may
6.21exclude special demonstration projects under subdivision 23.
6.22(g) Effective for services rendered on or after January 1, 2011, through December
6.2331, 2011, the commissioner shall include as part of the performance targets described
6.24in paragraph (c) a reduction in the health plan's emergency room utilization rate for
6.25state health care program enrollees by a measurable rate of five percent from the plan's
6.26utilization rate for state health care program enrollees for the previous calendar year.
6.27Effective for services rendered on or after January 1, 2012, the commissioner shall
6.28include as part of the performance targets described in paragraph (c) a reduction in the
6.29health plan's emergency room utilization rate for state health care program enrollees by a
6.30measurable rate of ten percent from the plan's utilization rate for state health care program
6.31enrollees for the previous calendar year.
6.32The withheld funds must be returned no sooner than July 1 and no later than July 31
6.33of the following calendar year if the managed care plan demonstrates to the satisfaction of
6.34the commissioner that
6.35The withhold described in this paragraph shall continue for each consecutive
6.36contract period until the plan's emergency room utilization rate for state health care
7.1program enrollees is reduced by 25 percent of the plan's emergency room utilization
7.2rate for state health care program enrollees for calendar year 2009. Hospitals shall
7.3cooperate with the health plans in meeting this performance target and shall accept
7.4payment withholds that may be returned to the hospitals if the performance target is
7.5achieved.
7.6
7.7
7.8county-based purchasing plans.
7.9(h) Effective for services rendered on or after January 1, 2012, the commissioner
7.10shall include as part of the performance targets described in paragraph (c) a reduction in
7.11the plan's hospitalization admission rate for hospitalizations for state health care program
7.12enrollees by a measurable rate of five percent from the plan's utilization rate for state
7.13health care program enrollees for the previous calendar year.
7.14The withheld funds must be returned no sooner than July 1 and no later than July
7.1531 of the following calendar year if the managed care plan or county-based purchasing
7.16plan demonstrates to the satisfaction of the commissioner that this reduction in the
7.17hospitalization rate was achieved.
7.18The withhold described in this paragraph shall continue for three consecutive
7.19contract periods. Hospitals shall cooperate with the plans in meeting this performance
7.20target and shall accept payment withholds that may be returned to the hospitals if the
7.21performance target is achieved.
7.22
7.2331, 2011, the commissioner shall withhold 4.5 percent of managed care plan payments
7.24under this section and county-based purchasing plan payments under section
7.26sooner than July 1 and no later than July 31 of the following year. The commissioner may
7.27exclude special demonstration projects under subdivision 23.
7.28
7.2931, 2012, the commissioner shall withhold 4.5 percent of managed care plan payments
7.30under this section and county-based purchasing plan payments under section
7.32sooner than July 1 and no later than July 31 of the following year. The commissioner may
7.33exclude special demonstration projects under subdivision 23.
7.34
7.3531, 2013, the commissioner shall withhold 4.5 percent of managed care plan payments
7.36under this section and county-based purchasing plan payments under section
8.2sooner than July 1 and no later than July 31 of the following year. The commissioner may
8.3exclude special demonstration projects under subdivision 23.
8.4
8.5shall withhold three percent of managed care plan payments under this section and
8.6county-based purchasing plan payments under section
8.7assistance program. The withheld funds must be returned no sooner than July 1 and
8.8no later than July 31 of the following year. The commissioner may exclude special
8.9demonstration projects under subdivision 23.
8.10
8.12under this section that is reasonably expected to be returned.
8.13
8.14from the set-aside and preference provisions of section
8.15(a), and 7.
8.16
8.17subject to the requirements of paragraph (c).
8.18 Sec. 5. Minnesota Statutes 2010, section 256B.69, subdivision 5i, is amended to read:
8.19 Subd. 5i. Administrative expenses. (a) Managed care plan and county-based
8.20purchasing plan administrative costs for a prepaid health plan provided under this section
8.21or section
8.22or county-based purchasing plan's actual calculated administrative spending for the
8.23previous calendar year as a percentage of total revenue. The penalty for exceeding this
8.24limit must be the amount of administrative spending in excess of 105 percent of the actual
8.25calculated amount. The commissioner may waive this penalty if the excess administrative
8.26spending is the result of unexpected shifts in enrollment or member needs or new program
8.27requirements.
8.28 (b) Expenses listed under section
8.29allowable administrative expenses for rate-setting purposes under this section, unless
8.30approved by the commissioner.
8.31(c) Notwithstanding paragraph (a), the portion of the per member per month
8.32capitation rate paid under this section to managed care plans and county-based purchasing
8.33plans for administrative expenditures shall be reduced by 21 cents beginning July 1, 2011.
8.34 Sec. 6. Minnesota Statutes 2010, section 256B.69, subdivision 28, is amended to read:
9.1 Subd. 28. Medicare special needs plans; medical assistance basic health care.
9.2 (a) The commissioner may contract with qualified Medicare-approved special needs
9.3plans to provide medical assistance basic health care services to persons with disabilities,
9.4including those with developmental disabilities. Basic health care services include:
9.5 (1) those services covered by the medical assistance state plan except for ICF/MR
9.6services, home and community-based waiver services, case management for persons with
9.7developmental disabilities under section
9.8and certain home care services defined by the commissioner in consultation with the
9.9stakeholder group established under paragraph (d); and
9.10 (2) basic health care services may also include risk for up to 100 days of nursing
9.11facility services for persons who reside in a noninstitutional setting and home health
9.12services related to rehabilitation as defined by the commissioner after consultation with
9.13the stakeholder group.
9.14 The commissioner may exclude other medical assistance services from the basic
9.15health care benefit set. Enrollees in these plans can access any excluded services on the
9.16same basis as other medical assistance recipients who have not enrolled.
9.17
9.18
9.19
9.20 (b) Beginning January 1, 2007, the commissioner may contract with qualified
9.21Medicare special needs plans to provide basic health care services under medical
9.22assistance to persons who are dually eligible for both Medicare and Medicaid and those
9.23Social Security beneficiaries eligible for Medicaid but in the waiting period for Medicare.
9.24The commissioner shall consult with the stakeholder group under paragraph (d) in
9.25developing program specifications for these services. The commissioner shall report to
9.26the chairs of the house of representatives and senate committees with jurisdiction over
9.27health and human services policy and finance by February 1, 2007, on implementation
9.28of these programs and the need for increased funding for the ombudsman for managed
9.29care and other consumer assistance and protections needed due to enrollment in managed
9.30care of persons with disabilities. Payment for Medicaid services provided under this
9.31subdivision for the months of May and June will be made no earlier than July 1 of the
9.32same calendar year.
9.33 (c) Notwithstanding subdivision 4, beginning January 1,
9.34commissioner
9.35with disabilities
9.36unless the individual chooses to opt-out of enrollment. The commissioner shall establish
10.1enrollment and opt out procedures consistent with applicable enrollment procedures under
10.2this subdivision.
10.3 (d) The commissioner shall establish a state-level stakeholder group to provide
10.4advice on managed care programs for persons with disabilities, including both MnDHO
10.5and contracts with special needs plans that provide basic health care services as described
10.6in paragraphs (a) and (b). The stakeholder group shall provide advice on program
10.7expansions under this subdivision and subdivision 23, including:
10.8 (1) implementation efforts;
10.9 (2) consumer protections; and
10.10 (3) program specifications such as quality assurance measures, data collection and
10.11reporting, and evaluation of costs, quality, and results.
10.12 (e) Each plan under contract to provide medical assistance basic health care services
10.13shall establish a local or regional stakeholder group, including representatives of the
10.14counties covered by the plan, members, consumer advocates, and providers, for advice on
10.15issues that arise in the local or regional area.
10.16 (f) The commissioner is prohibited from providing the names of potential enrollees
10.17to health plans for marketing purposes. The commissioner may mail marketing materials
10.18to potential enrollees on behalf of health plans, in which case the health plans shall cover
10.19any costs incurred by the commissioner for mailing marketing materials.
10.20 Sec. 7. Minnesota Statutes 2010, section 256L.12, subdivision 9, is amended to read:
10.21 Subd. 9. Rate setting; performance withholds. (a) Rates will be prospective,
10.22per capita, where possible. The commissioner may allow health plans to arrange for
10.23inpatient hospital services on a risk or nonrisk basis. The commissioner shall consult with
10.24an independent actuary to determine appropriate rates.
10.25 (b) For services rendered on or after January 1, 2004, the commissioner shall
10.26withhold five percent of managed care plan payments and county-based purchasing
10.27plan payments under this section pending completion of performance targets. Each
10.28performance target must be quantifiable, objective, measurable, and reasonably attainable,
10.29except in the case of a performance target based on a federal or state law or rule. Criteria
10.30for assessment of each performance target must be outlined in writing prior to the
10.31contract effective date. The managed care plan must demonstrate, to the commissioner's
10.32satisfaction, that the data submitted regarding attainment of the performance target is
10.33accurate. The commissioner shall periodically change the administrative measures used
10.34as performance targets in order to improve plan performance across a broader range of
10.35administrative services. The performance targets must include measurement of plan
11.1efforts to contain spending on health care services and administrative activities. The
11.2commissioner may adopt plan-specific performance targets that take into account factors
11.3affecting only one plan, such as characteristics of the plan's enrollee population. The
11.4withheld funds must be returned no sooner than July 1 and no later than July 31 of the
11.5following calendar year if performance targets in the contract are achieved.
11.6(c) For services rendered on or after January 1, 2011, the commissioner shall
11.7withhold an additional three percent of managed care plan or county-based purchasing
11.8plan payments under this section. The withheld funds must be returned no sooner than
11.9July 1 and no later than July 31 of the following calendar year. The return of the withhold
11.10under this paragraph is not subject to the requirements of paragraph (b).
11.11(d) Effective for services rendered on or after January 1, 2011, through December
11.1231, 2011, the commissioner shall include as part of the performance targets described in
11.13paragraph (b) a reduction in the plan's emergency room utilization rate for state health
11.14care program enrollees by a measurable rate of five percent from the plan's utilization
11.15rate for the previous calendar year. Effective for services rendered on or after January
11.161, 2012, the commissioner shall include as part of the performance targets described in
11.17paragraph (b) a reduction in the plan's emergency room utilization rate for state health
11.18care program enrollees by a measurable rate of ten percent from the plan's utilization
11.19rate for the previous calendar year.
11.20The withheld funds must be returned no sooner than July 1 and no later than July 31
11.21of the following calendar year if the managed care plan demonstrates to the satisfaction of
11.22the commissioner that
11.23The withhold described in this paragraph shall continue for each consecutive
11.24contract period until the plan's emergency room utilization rate for state health care
11.25program enrollees is reduced by 25 percent of the plan's emergency room utilization rate
11.26for state health care program enrollees for calendar year 2009. Hospitals shall cooperate
11.27with the health plans in meeting this performance target and shall accept payment
11.28withholds that may be returned to the hospitals if the performance target is achieved.
11.29
11.30
11.31
11.32county-based purchasing plans.
11.33(e) Effective for services rendered on or after January 1, 2012, the commissioner
11.34shall include as part of the performance targets described in paragraph (b) a reduction
11.35in the plan's hospitalization admission rate for state health care program enrollees by
12.1a measurable rate of five percent from the plan's hospitalization rate for the previous
12.2calendar year.
12.3The withheld funds must be returned no sooner than July 1 and no later than July
12.431 of the following calendar year if the managed care plan or county-based purchasing
12.5plan demonstrates to the satisfaction of the commissioner that this reduction in the
12.6hospitalization rate was achieved.
12.7The withhold described in this paragraph shall continue for three consecutive
12.8contract periods. Hospitals shall cooperate with the plans in meeting this performance
12.9target and shall accept payment withholds that may be returned to the hospitals if the
12.10performance target is achieved.
12.11
12.13under this section that is reasonably expected to be returned.
12.14 Sec. 8. Laws 2009, chapter 79, article 13, section 3, subdivision 8, as amended by
12.15Laws 2009, chapter 173, article 2, section 1, subdivision 8, Laws 2010, First Special
12.16Session chapter 1, article 15, section 5, and Laws 2010, First Special Session chapter 1,
12.17article 25, section 16, is amended to read:
| 12.18 |
Subd. 8.Continuing Care Grants |
||||||
12.20appropriation for each purpose are as follows:
| 12.21 |
(a) Aging and Adult Services Grants |
13,499,000 |
15,805,000 |
||||
12.23increased by $5,751,000 in fiscal year 2012
12.24and $6,705,000 in fiscal year 2013.
12.25Information and Assistance
12.26Reimbursement. Federal administrative
12.27reimbursement obtained from information
12.28and assistance services provided by the
12.29Senior LinkAge or Disability Linkage lines
12.30to people who are identified as eligible for
12.31medical assistance shall be appropriated to
12.32the commissioner for this activity.
12.33Community Service Development Grant
12.34Reduction. Funding for community service
13.1development grants must be reduced by
13.2$260,000 for fiscal year 2010; $284,000 in
13.3fiscal year 2011; $43,000 in fiscal year 2012;
13.4and $43,000 in fiscal year 2013. Base level
13.5funding shall be restored in fiscal year 2014.
13.6Community Service Development Grant
13.7Community Initiative. Funding for
13.8community service development grants shall
13.9be used to offset the cost of aging support
13.10grants. Base level funding shall be restored
13.11in fiscal year 2014.
13.12Senior Nutrition Use of Federal Funds.
13.13For fiscal year 2010, general fund grants
13.14for home-delivered meals and congregate
13.15dining shall be reduced by $500,000. The
13.16commissioner must replace these general
13.17fund reductions with equal amounts from
13.18federal funding for senior nutrition from the
13.19American Recovery and Reinvestment Act
13.20of 2009.
| 13.21 |
(b) Alternative Care Grants |
50,234,000 |
48,576,000 |
||||
13.23decreased by $3,598,000 in fiscal year 2012
13.24and $3,470,000 in fiscal year 2013.
13.25Alternative Care Transfer. Any money
13.26allocated to the alternative care program that
13.27is not spent for the purposes indicated does
13.28not cancel but must be transferred to the
13.29medical assistance account.
| 13.30 13.31 |
(c) Medical Assistance Grants; Long-Term Care Facilities. |
367,444,000 |
419,749,000 |
||||
| 13.32 13.33 |
(d) Medical Assistance Long-Term Care Waivers and Home Care Grants |
853,567,000 |
1,039,517,000 |
||||
13.35Waivers. During the fiscal years beginning
14.1on July 1, 2009, and July 1, 2010, the
14.2commissioner shall allocate money for home
14.3and community-based waiver programs
14.4under Minnesota Statutes, section
14.5to ensure a reduction in state spending that is
14.6equivalent to limiting the caseload growth of
14.7the TBI waiver to 12.5 allocations per month
14.8each year of the biennium and the CADI
14.9waiver to 95 allocations per month each year
14.10of the biennium. Limits do not apply: (1)
14.11when there is an approved plan for nursing
14.12facility bed closures for individuals under
14.13age 65 who require relocation due to the
14.14bed closure; (2) to fiscal year 2009 waiver
14.15allocations delayed due to unallotment; or (3)
14.16to transfers authorized by the commissioner
14.17from the personal care assistance program
14.18of individuals having a home care rating
14.19of "CS," "MT," or "HL." Priorities for the
14.20allocation of funds must be for individuals
14.21anticipated to be discharged from institutional
14.22settings or who are at imminent risk of a
14.23placement in an institutional setting.
14.24Manage Growth in DD Waiver. The
14.25commissioner shall manage the growth in
14.26the DD waiver by limiting the allocations
14.27included in the February 2009 forecast to 15
14.28additional diversion allocations each month
14.29for the calendar years that begin on January
14.301, 2010, and January 1, 2011. Additional
14.31allocations must be made available for
14.32transfers authorized by the commissioner
14.33from the personal care program of individuals
14.34having a home care rating of "CS," "MT,"
14.35or "HL."
15.1Adjustment to Lead Agency Waiver
15.2Allocations. Prior to the availability of the
15.3alternative license defined in Minnesota
15.4Statutes, section
15.5the commissioner shall reduce lead agency
15.6waiver allocations for the purposes of
15.7implementing a moratorium on corporate
15.8foster care.
15.9
15.10
15.11
15.12
15.13
15.14
15.15
15.16
15.17
15.18
15.19
15.20
| 15.21 |
(e) Mental Health Grants |
||||||
| 15.22 |
Appropriations by Fund |
||
| 15.23 |
General |
77,739,000 |
77,739,000 |
| 15.24 |
Health Care Access |
750,000 |
750,000 |
| 15.25 |
Lottery Prize |
1,508,000 |
1,508,000 |
15.27year's appropriation for adult mental health
15.28grants may be used to fund allocations in that
15.29portion of the fiscal year ending December
15.3031.
| 15.31 |
(f) Deaf and Hard-of-Hearing Grants |
1,930,000 |
1,917,000 |
||||
| 15.32 |
(g) Chemical Dependency Entitlement Grants |
111,303,000 |
122,822,000 |
||||
15.34For placements beginning during fiscal years
15.352010 and 2011, county-negotiated rates and
16.1provider claims to the consolidated chemical
16.2dependency fund must not exceed the lesser
16.3of:
16.4(1) rates charged for these services on
16.5January 1, 2009;
16.6(2) 160 percent of the average rate on January
16.71, 2009, for each group of vendors with
16.8similar attributes.
16.9Rates for fiscal years 2010 and 2011 must
16.10not exceed 160 percent of the average rate on
16.11January 1, 2009, for each group of vendors
16.12with similar attributes.
16.13Effective July 1, 2010, rates that were above
16.14the average rate on January 1, 2009, are
16.15reduced by five percent from the rates in
16.16effect on June 1, 2010. Rates below the
16.17average rate on January 1, 2009, are reduced
16.18by 1.8 percent from the rates in effect on
16.19June 1, 2010. Services provided under
16.20this section by state-operated services are
16.21exempt from the rate reduction. For services
16.22provided in fiscal years 2012 and 2013, the
16.23statewide aggregate payment under the new
16.24rate methodology to be developed under
16.25Minnesota Statutes, section
16.26not exceed the projected aggregate payment
16.27under the rates in effect for fiscal year 2011
16.28excluding the rate reduction for rates that
16.29were below the average on January 1, 2009,
16.30plus a state share increase of $3,787,000 for
16.31fiscal year 2012 and $5,023,000 for fiscal
16.32year 2013. Notwithstanding any provision
16.33to the contrary in this article, this provision
16.34expires on June 30, 2013.
17.1Chemical Dependency Special Revenue
17.2Account. For fiscal year 2010, $750,000
17.3must be transferred from the consolidated
17.4chemical dependency treatment fund
17.5administrative account and deposited into the
17.6general fund.
17.7County CD Share of MA Costs for
17.8ARRA Compliance. Notwithstanding the
17.9provisions of Minnesota Statutes, chapter
17.10254B, for chemical dependency services
17.11provided during the period October 1, 2008,
17.12to December 31, 2010, and reimbursed by
17.13medical assistance at the enhanced federal
17.14matching rate provided under the American
17.15Recovery and Reinvestment Act of 2009, the
17.16county share is 30 percent of the nonfederal
17.17share. This provision is effective the day
17.18following final enactment.
| 17.19 17.20 |
(h) Chemical Dependency Nonentitlement Grants |
1,729,000 |
1,729,000 |
||||
| 17.21 |
(i) Other Continuing Care Grants |
19,201,000 |
17,528,000 |
||||
17.23increased by $2,639,000 in fiscal year 2012
17.24and increased by $3,854,000 in fiscal year
17.252013.
17.26Technology Grants. $650,000 in fiscal
17.27year 2010 and $1,000,000 in fiscal year
17.282011 are for technology grants, case
17.29consultation, evaluation, and consumer
17.30information grants related to developing and
17.31supporting alternatives to shift-staff foster
17.32care residential service models.
17.33Other Continuing Care Grants; HIV
17.34Grants. Money appropriated for the HIV
17.35drug and insurance grant program in fiscal
18.1year 2010 may be used in either year of the
18.2biennium.
18.3Quality Assurance Commission. Effective
18.4July 1, 2009, state funding for the quality
18.5assurance commission under Minnesota
18.6Statutes, section
18.7 Sec. 9. CAPITATION PAYMENT DELAY.
18.8(a) The commissioner of human services shall delay the MinnesotaCare capitation
18.9payment due in May of 2013 to managed care plans for single adults without children
18.10eligible under Minnesota Statutes, section 256L.04, subdivision 7, until July of 2013.
18.11(b) The commissioner of human services shall delay payments due in April of 2013
18.12for medical assistance services provided under Minnesota Statutes, section 256B.69,
18.13subdivision 28, until after July 1, 2013.
18.14 Sec. 10. HEALTH CARE DELIVERY SYSTEMS DEMONSTRATION
18.15PROJECT.
18.16 Subdivision 1. Implementation. (a) The commissioner shall develop and authorize
18.17a demonstration project to test alternative and innovative health care delivery systems,
18.18including accountable care organizations that provide services to a specified patient
18.19population for an agreed-upon total cost of care payment arrangement in accordance with
18.20subdivision 4. The commissioner shall develop one request for proposals to provide
18.21services to the elderly population eligible for medical assistance, and one request for
18.22proposals to provide services to families and children eligible for medical assistance
18.23and the MinnesotaCare program.
18.24(b) In developing the request for proposals, the commissioner shall:
18.25(1) establish uniform statewide methods of forecasting utilization and cost of care
18.26for the specified populations, to be used by the commissioner for the health care delivery
18.27system projects;
18.28(2) identify key indicators of quality, access, patient satisfaction, and other
18.29performance indicators that will be measured, in addition to indicators for measuring
18.30cost savings;
18.31(3) allow maximum flexibility to encourage innovation and variation so that a variety
18.32of provider collaborations are able to become health care delivery systems; and
18.33(4) establish quality standards for the delivery system demonstrations.
19.1(c) To be eligible to participate in the demonstration project, a health care delivery
19.2system must:
19.3(1) provide required covered services and care coordination to recipients enrolled in
19.4the demonstration project;
19.5(2) establish a process to ensure the quality of care provided;
19.6(3) in cooperation with counties and community social service agencies, coordinate
19.7the delivery of health care services with existing social services programs;
19.8(4) provide a system for advocacy and consumer protection; and
19.9(5) adopt innovative and cost-effective methods of care delivery and coordination,
19.10which may include the use of allied health professionals, telemedicine, patient educators,
19.11care coordinators, and community health workers.
19.12(d) A health care delivery system demonstration may be formed by the following
19.13groups of providers of services and suppliers if they have established a mechanism for
19.14shared governance:
19.15(1) professionals in group practice arrangements;
19.16(2) networks of individual practices of professionals;
19.17(3) partnerships or joint venture arrangements between hospitals and health care
19.18professionals;
19.19(4) hospitals employing professionals; and
19.20(5) other groups of providers of services and suppliers as the commissioner
19.21determines appropriate.
19.22A managed care plan or county-based purchasing plan may participate in this
19.23demonstration in collaboration with one or more of the entities listed in clauses (1) to (5).
19.24A health care delivery system may contract with a managed care plan or a
19.25county-based purchasing plan to provide administrative services, including the
19.26administration of a payment system using the payment methods approved by the
19.27commissioner for health care delivery systems.
19.28(e) The commissioner may require a health care delivery system to enter into
19.29additional third-party contractual relationships for the assessment of risk and purchase of
19.30stop loss insurance or another form of insurance risk management related to the delivery
19.31of care described in paragraph (c).
19.32 Subd. 2. Enrollment. (a) The commissioner shall develop and authorize at least
19.33two demonstration projects: one for families and children eligible for medical assistance
19.34and MinnesotaCare; and one for individuals 65 years of age or older eligible for medical
19.35assistance.
20.1(b) Eligible applicants and recipients shall enroll in a health care delivery system
20.2if a system serves the county in which the applicant or recipient resides. If more than
20.3one health care delivery system serves a county, the applicant or recipient may choose
20.4among the delivery systems. The commissioner shall assign an applicant or recipient to a
20.5health care delivery system if a health care delivery system is available and no choice has
20.6been made by the applicant or recipient.
20.7 Subd. 3. Accountability. (a) Health care delivery systems must accept responsibility
20.8for the quality of care based on standards established under subdivision 1, paragraph (b),
20.9clause (4), and the cost of care or utilization of services provided to its enrollees under
20.10subdivision 1, paragraph (b), clause (1).
20.11(b) A health care delivery system may contract and coordinate with providers and
20.12clinics for the delivery of services and shall contract with community health clinics,
20.13federally qualified health centers, community mental health centers or programs, and rural
20.14clinics to the extent practicable.
20.15 Subd. 4. Payment system. (a) In developing a payment system for health care
20.16delivery systems, the commissioner shall establish a total cost of care benchmark to be
20.17paid for services provided to the recipients enrolled in a health care delivery system.
20.18(b) The total cost of care payment system shall not exceed the payments made
20.19in fiscal year 2011 by the commissioner under fee-for-service or managed care for the
20.20delivery of services to the specified populations within the geographic area served by the
20.21health care delivery system minus five percent.
20.22(c) The payment system developed under this section shall incorporate the withhold
20.23and performance target requirements in Minnesota Statutes, section 256B.69, subdivision
20.245a.
20.25 Sec. 11. MANAGE GROWTH IN TRAUMATIC BRAIN INJURY AND
20.26COMMUNITY ALTERNATIVES FOR DISABLED INDIVIDUALS WAIVERS.
20.27During the fiscal years beginning July 1, 2011, and July 1, 2012, the commissioner
20.28shall allocate money for home and community-based waiver programs under Minnesota
20.29Statutes, section
20.30limiting the caseload growth of the traumatic brain injury waiver to six allocations per
20.31month each year of the biennium and the community alternatives for disabled individuals
20.32waiver to 60 allocations per month. The limits do not apply:
20.33(1) when there is an approved plan for nursing facility bed closures for individuals
20.34under age 65 who require relocation due to the bed closure;
20.35(2) to fiscal year 2009 waiver allocations delayed due to unallotment; or
21.1(3) to transfers authorized by the commissioner from the personal care assistance
21.2program of individuals having a home care rating of CS, MT, or HL. Priorities for the
21.3allocation of funds must be for individuals anticipated to be discharged from institutional
21.4settings or who are at imminent risk of a placement in an institutional setting.
21.5 Sec. 12. MANAGE GROWTH IN DEVELOPMENTAL DISABILITY (DD)
21.6WAIVER.
21.7The commissioner shall manage the growth in the developmental disability waiver
21.8by limiting the allocations included in the November 2010 forecast to six additional
21.9diversion allocations each month for the fiscal year that begins on July 1, 2011. Additional
21.10allocations must be made available for transfers authorized by the commissioner from the
21.11personal care assistance program of individuals having a home care rating of CS, MT,
21.12or HL. This provision is effective through June 30, 2013.
21.13 Sec. 13. REQUEST FOR PROPOSALS; CLAIMS PROCESSING FOR
21.14FEE-FOR-SERVICE MEDICAL ASSISTANCE.
21.15(a) The commissioner of human services shall issue a request for proposal for a
21.16contract to provide claims processing services for the fee-for-service medical assistance
21.17program, excluding outpatient pharmacy services. The contractor must be able to:
21.18(1) process provider claims in a timely manner and within state and federal
21.19requirements;
21.20(2) provide electronic claims submission access for providers;
21.21(3) validate claims data;
21.22(4) file and reconcile claims;
21.23(5) identify fraud and abuse;
21.24(6) measure quality assurance and performance outcomes; and
21.25(7) coordinate benefits on the front end of a claim.
21.26(b) The commissioner shall enter into a contract for claims processing by January 1,
21.272012. Payment under the contract shall not exceed $1.75 on average per claim processed.
21.28(c) The commissioner shall apply for any federal grants that may be available.
21.29EFFECTIVE DATE.This section is effective the day following final enactment.
