Bill Text: MN SF959 | 2013-2014 | 88th Legislature | Introduced
Bill Title: Medical assistance (MA) managed care contracts home care services provisions modifications
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2013-03-04 - Referred to Health, Human Services and Housing [SF959 Detail]
Download: Minnesota-2013-SF959-Introduced.html
1.2relating to human services; modifying medical assistance managed care
1.3contracts;amending Minnesota Statutes 2012, section 256B.69, subdivision 5a.
1.4BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.5 Section 1. Minnesota Statutes 2012, section 256B.69, subdivision 5a, is amended to
1.6read:
1.7 Subd. 5a. Managed care contracts. (a) Managed care contracts under this section
1.8and section256L.12 shall be entered into or renewed on a calendar year basis beginning
1.9January 1, 1996. Managed care contracts which were in effect on June 30, 1995, and set to
1.10renew on July 1, 1995, shall be renewed for the period July 1, 1995 through December
1.1131, 1995 at the same terms that were in effect on June 30, 1995. The commissioner may
1.12issue separate contracts with requirements specific to services to medical assistance
1.13recipients age 65 and older.
1.14 (b) A prepaid health plan providing covered health services for eligible persons
1.15pursuant to chapters 256B and 256L is responsible for complying with the terms of its
1.16contract with the commissioner. Requirements applicable to managed care programs
1.17under chapters 256B and 256L established after the effective date of a contract with the
1.18commissioner take effect when the contract is next issued or renewed.
1.19 (c) Effective for services rendered on or after January 1, 2003, the commissioner
1.20shall withhold five percent of managed care plan payments under this section and
1.21county-based purchasing plan payments under section256B.692 for the prepaid medical
1.22assistance program pending completion of performance targets. Each performance target
1.23must be quantifiable, objective, measurable, and reasonably attainable, except in the case
1.24of a performance target based on a federal or state law or rule. Criteria for assessment
2.1of each performance target must be outlined in writing prior to the contract effective
2.2date. Clinical or utilization performance targets and their related criteria must consider
2.3evidence-based research and reasonable interventions when available or applicable to the
2.4populations served, and must be developed with input from external clinical experts
2.5and stakeholders, including managed care plans, county-based purchasing plans, and
2.6providers. The managed care or county-based purchasing plan must demonstrate,
2.7to the commissioner's satisfaction, that the data submitted regarding attainment of
2.8the performance target is accurate. The commissioner shall periodically change the
2.9administrative measures used as performance targets in order to improve plan performance
2.10across a broader range of administrative services. The performance targets must include
2.11measurement of plan efforts to contain spending on health care services and administrative
2.12activities. The commissioner may adopt plan-specific performance targets that take into
2.13account factors affecting only one plan, including characteristics of the plan's enrollee
2.14population. The withheld funds must be returned no sooner than July of the following
2.15year if performance targets in the contract are achieved. The commissioner may exclude
2.16special demonstration projects under subdivision 23.
2.17 (d) Effective for services rendered on or after January 1, 2009, through December
2.1831, 2009, the commissioner shall withhold three percent of managed care plan payments
2.19under this section and county-based purchasing plan payments under section256B.692
2.20for the prepaid medical assistance program. The withheld funds must be returned no
2.21sooner than July 1 and no later than July 31 of the following year. The commissioner may
2.22exclude special demonstration projects under subdivision 23.
2.23(e) Effective for services provided on or after January 1,2010 2014, the
2.24commissioner shall require that managed care plans use the assessment and authorization
2.25processes, forms, timelines, standards, documentation, and data reporting requirements,
2.26protocols, billing processes, and policies consistent with medical assistance fee-for-service
2.27or the Department of Human Services contract requirements consistent with medical
2.28assistance fee-for-service or the Department of Human Services contract requirements
2.29for allpersonal care assistance services under section
256B.0659
2.30under section 256B.0651.
2.31(f) Effective for services rendered on or after January 1, 2010, through December
2.3231, 2010, the commissioner shall withhold 4.5 percent of managed care plan payments
2.33under this section and county-based purchasing plan payments under section256B.692
2.34for the prepaid medical assistance program. The withheld funds must be returned no
2.35sooner than July 1 and no later than July 31 of the following year. The commissioner may
2.36exclude special demonstration projects under subdivision 23.
3.1(g) Effective for services rendered on or after January 1, 2011, through December
3.231, 2011, the commissioner shall include as part of the performance targets described in
3.3paragraph (c) a reduction in the health plan's emergency room utilization rate for state
3.4health care program enrollees by a measurable rate of five percent from the plan's utilization
3.5rate for state health care program enrollees for the previous calendar year. Effective for
3.6services rendered on or after January 1, 2012, the commissioner shall include as part of the
3.7performance targets described in paragraph (c) a reduction in the health plan's emergency
3.8department utilization rate for medical assistance and MinnesotaCare enrollees, as
3.9determined by the commissioner. For 2012, the reduction shall be based on the health plan's
3.10utilization in 2009. To earn the return of the withhold each subsequent year, the managed
3.11care plan or county-based purchasing plan must achieve a qualifying reduction of no less
3.12than ten percent of the plan's emergency department utilization rate for medical assistance
3.13and MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions
3.1423 and 28, compared to the previous measurement year until the final performance target
3.15is reached. When measuring performance, the commissioner must consider the difference
3.16in health risk in a managed care or county-based purchasing plan's membership in the
3.17baseline year compared to the measurement year, and work with the managed care or
3.18county-based purchasing plan to account for differences that they agree are significant.
3.19The withheld funds must be returned no sooner than July 1 and no later than July 31
3.20of the following calendar year if the managed care plan or county-based purchasing plan
3.21demonstrates to the satisfaction of the commissioner that a reduction in the utilization rate
3.22was achieved. The commissioner shall structure the withhold so that the commissioner
3.23returns a portion of the withheld funds in amounts commensurate with achieved reductions
3.24in utilization less than the targeted amount.
3.25The withhold described in this paragraph shall continue for each consecutive contract
3.26period until the plan's emergency room utilization rate for state health care program
3.27enrollees is reduced by 25 percent of the plan's emergency room utilization rate for medical
3.28assistance and MinnesotaCare enrollees for calendar year 2009. Hospitals shall cooperate
3.29with the health plans in meeting this performance target and shall accept payment
3.30withholds that may be returned to the hospitals if the performance target is achieved.
3.31(h) Effective for services rendered on or after January 1, 2012, the commissioner
3.32shall include as part of the performance targets described in paragraph (c) a reduction
3.33in the plan's hospitalization admission rate for medical assistance and MinnesotaCare
3.34enrollees, as determined by the commissioner. To earn the return of the withhold each
3.35year, the managed care plan or county-based purchasing plan must achieve a qualifying
3.36reduction of no less than five percent of the plan's hospital admission rate for medical
4.1assistance and MinnesotaCare enrollees, excluding enrollees in programs described in
4.2subdivisions 23 and 28, compared to the previous calendar year until the final performance
4.3target is reached. When measuring performance, the commissioner must consider the
4.4difference in health risk in a managed care or county-based purchasing plan's membership
4.5in the baseline year compared to the measurement year, and work with the managed care
4.6or county-based purchasing plan to account for differences that they agree are significant.
4.7The withheld funds must be returned no sooner than July 1 and no later than July
4.831 of the following calendar year if the managed care plan or county-based purchasing
4.9plan demonstrates to the satisfaction of the commissioner that this reduction in the
4.10hospitalization rate was achieved. The commissioner shall structure the withhold so that
4.11the commissioner returns a portion of the withheld funds in amounts commensurate with
4.12achieved reductions in utilization less than the targeted amount.
4.13The withhold described in this paragraph shall continue until there is a 25 percent
4.14reduction in the hospital admission rate compared to the hospital admission rates in
4.15calendar year 2011, as determined by the commissioner. The hospital admissions in this
4.16performance target do not include the admissions applicable to the subsequent hospital
4.17admission performance target under paragraph (i). Hospitals shall cooperate with the
4.18plans in meeting this performance target and shall accept payment withholds that may be
4.19returned to the hospitals if the performance target is achieved.
4.20(i) Effective for services rendered on or after January 1, 2012, the commissioner
4.21shall include as part of the performance targets described in paragraph (c) a reduction in
4.22the plan's hospitalization admission rates for subsequent hospitalizations within 30 days of
4.23a previous hospitalization of a patient regardless of the reason, for medical assistance and
4.24MinnesotaCare enrollees, as determined by the commissioner. To earn the return of the
4.25withhold each year, the managed care plan or county-based purchasing plan must achieve
4.26a qualifying reduction of the subsequent hospitalization rate for medical assistance and
4.27MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions 23
4.28and 28, of no less than five percent compared to the previous calendar year until the
4.29final performance target is reached.
4.30The withheld funds must be returned no sooner than July 1 and no later than July
4.3131 of the following calendar year if the managed care plan or county-based purchasing
4.32plan demonstrates to the satisfaction of the commissioner that a qualifying reduction in
4.33the subsequent hospitalization rate was achieved. The commissioner shall structure the
4.34withhold so that the commissioner returns a portion of the withheld funds in amounts
4.35commensurate with achieved reductions in utilization less than the targeted amount.
5.1The withhold described in this paragraph must continue for each consecutive
5.2contract period until the plan's subsequent hospitalization rate for medical assistance and
5.3MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions 23
5.4and 28, is reduced by 25 percent of the plan's subsequent hospitalization rate for calendar
5.5year 2011. Hospitals shall cooperate with the plans in meeting this performance target and
5.6shall accept payment withholds that must be returned to the hospitals if the performance
5.7target is achieved.
5.8(j) Effective for services rendered on or after January 1, 2011, through December 31,
5.92011, the commissioner shall withhold 4.5 percent of managed care plan payments under
5.10this section and county-based purchasing plan payments under section256B.692 for the
5.11prepaid medical assistance program. The withheld funds must be returned no sooner than
5.12July 1 and no later than July 31 of the following year. The commissioner may exclude
5.13special demonstration projects under subdivision 23.
5.14(k) Effective for services rendered on or after January 1, 2012, through December
5.1531, 2012, the commissioner shall withhold 4.5 percent of managed care plan payments
5.16under this section and county-based purchasing plan payments under section256B.692
5.17for the prepaid medical assistance program. The withheld funds must be returned no
5.18sooner than July 1 and no later than July 31 of the following year. The commissioner may
5.19exclude special demonstration projects under subdivision 23.
5.20(l) Effective for services rendered on or after January 1, 2013, through December 31,
5.212013, the commissioner shall withhold 4.5 percent of managed care plan payments under
5.22this section and county-based purchasing plan payments under section256B.692 for the
5.23prepaid medical assistance program. The withheld funds must be returned no sooner than
5.24July 1 and no later than July 31 of the following year. The commissioner may exclude
5.25special demonstration projects under subdivision 23.
5.26(m) Effective for services rendered on or after January 1, 2014, the commissioner
5.27shall withhold three percent of managed care plan payments under this section and
5.28county-based purchasing plan payments under section256B.692 for the prepaid medical
5.29assistance program. The withheld funds must be returned no sooner than July 1 and
5.30no later than July 31 of the following year. The commissioner may exclude special
5.31demonstration projects under subdivision 23.
5.32(n) A managed care plan or a county-based purchasing plan under section256B.692
5.33may include as admitted assets under section
62D.044 any amount withheld under this
5.34section that is reasonably expected to be returned.
6.1(o) Contracts between the commissioner and a prepaid health plan are exempt from
6.2the set-aside and preference provisions of section16C.16, subdivisions 6 , paragraph
6.3(a), and 7.
6.4(p) The return of the withhold under paragraphs (d), (f), and (j) to (m) is not subject
6.5to the requirements of paragraph (c).
1.3contracts;amending Minnesota Statutes 2012, section 256B.69, subdivision 5a.
1.4BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.5 Section 1. Minnesota Statutes 2012, section 256B.69, subdivision 5a, is amended to
1.6read:
1.7 Subd. 5a. Managed care contracts. (a) Managed care contracts under this section
1.8and section
1.9January 1, 1996. Managed care contracts which were in effect on June 30, 1995, and set to
1.10renew on July 1, 1995, shall be renewed for the period July 1, 1995 through December
1.1131, 1995 at the same terms that were in effect on June 30, 1995. The commissioner may
1.12issue separate contracts with requirements specific to services to medical assistance
1.13recipients age 65 and older.
1.14 (b) A prepaid health plan providing covered health services for eligible persons
1.15pursuant to chapters 256B and 256L is responsible for complying with the terms of its
1.16contract with the commissioner. Requirements applicable to managed care programs
1.17under chapters 256B and 256L established after the effective date of a contract with the
1.18commissioner take effect when the contract is next issued or renewed.
1.19 (c) Effective for services rendered on or after January 1, 2003, the commissioner
1.20shall withhold five percent of managed care plan payments under this section and
1.21county-based purchasing plan payments under section
1.22assistance program pending completion of performance targets. Each performance target
1.23must be quantifiable, objective, measurable, and reasonably attainable, except in the case
1.24of a performance target based on a federal or state law or rule. Criteria for assessment
2.1of each performance target must be outlined in writing prior to the contract effective
2.2date. Clinical or utilization performance targets and their related criteria must consider
2.3evidence-based research and reasonable interventions when available or applicable to the
2.4populations served, and must be developed with input from external clinical experts
2.5and stakeholders, including managed care plans, county-based purchasing plans, and
2.6providers. The managed care or county-based purchasing plan must demonstrate,
2.7to the commissioner's satisfaction, that the data submitted regarding attainment of
2.8the performance target is accurate. The commissioner shall periodically change the
2.9administrative measures used as performance targets in order to improve plan performance
2.10across a broader range of administrative services. The performance targets must include
2.11measurement of plan efforts to contain spending on health care services and administrative
2.12activities. The commissioner may adopt plan-specific performance targets that take into
2.13account factors affecting only one plan, including characteristics of the plan's enrollee
2.14population. The withheld funds must be returned no sooner than July of the following
2.15year if performance targets in the contract are achieved. The commissioner may exclude
2.16special demonstration projects under subdivision 23.
2.17 (d) Effective for services rendered on or after January 1, 2009, through December
2.1831, 2009, the commissioner shall withhold three percent of managed care plan payments
2.19under this section and county-based purchasing plan payments under section
2.21sooner than July 1 and no later than July 31 of the following year. The commissioner may
2.22exclude special demonstration projects under subdivision 23.
2.23(e) Effective for services provided on or after January 1,
2.24commissioner shall require that managed care plans use the assessment and authorization
2.25processes, forms, timelines, standards, documentation, and data reporting requirements,
2.26protocols, billing processes, and policies consistent with medical assistance fee-for-service
2.27or the Department of Human Services contract requirements consistent with medical
2.28assistance fee-for-service or the Department of Human Services contract requirements
2.29for all
2.30under section 256B.0651.
2.31(f) Effective for services rendered on or after January 1, 2010, through December
2.3231, 2010, the commissioner shall withhold 4.5 percent of managed care plan payments
2.33under this section and county-based purchasing plan payments under section
2.35sooner than July 1 and no later than July 31 of the following year. The commissioner may
2.36exclude special demonstration projects under subdivision 23.
3.1(g) Effective for services rendered on or after January 1, 2011, through December
3.231, 2011, the commissioner shall include as part of the performance targets described in
3.3paragraph (c) a reduction in the health plan's emergency room utilization rate for state
3.4health care program enrollees by a measurable rate of five percent from the plan's utilization
3.5rate for state health care program enrollees for the previous calendar year. Effective for
3.6services rendered on or after January 1, 2012, the commissioner shall include as part of the
3.7performance targets described in paragraph (c) a reduction in the health plan's emergency
3.8department utilization rate for medical assistance and MinnesotaCare enrollees, as
3.9determined by the commissioner. For 2012, the reduction shall be based on the health plan's
3.10utilization in 2009. To earn the return of the withhold each subsequent year, the managed
3.11care plan or county-based purchasing plan must achieve a qualifying reduction of no less
3.12than ten percent of the plan's emergency department utilization rate for medical assistance
3.13and MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions
3.1423 and 28, compared to the previous measurement year until the final performance target
3.15is reached. When measuring performance, the commissioner must consider the difference
3.16in health risk in a managed care or county-based purchasing plan's membership in the
3.17baseline year compared to the measurement year, and work with the managed care or
3.18county-based purchasing plan to account for differences that they agree are significant.
3.19The withheld funds must be returned no sooner than July 1 and no later than July 31
3.20of the following calendar year if the managed care plan or county-based purchasing plan
3.21demonstrates to the satisfaction of the commissioner that a reduction in the utilization rate
3.22was achieved. The commissioner shall structure the withhold so that the commissioner
3.23returns a portion of the withheld funds in amounts commensurate with achieved reductions
3.24in utilization less than the targeted amount.
3.25The withhold described in this paragraph shall continue for each consecutive contract
3.26period until the plan's emergency room utilization rate for state health care program
3.27enrollees is reduced by 25 percent of the plan's emergency room utilization rate for medical
3.28assistance and MinnesotaCare enrollees for calendar year 2009. Hospitals shall cooperate
3.29with the health plans in meeting this performance target and shall accept payment
3.30withholds that may be returned to the hospitals if the performance target is achieved.
3.31(h) Effective for services rendered on or after January 1, 2012, the commissioner
3.32shall include as part of the performance targets described in paragraph (c) a reduction
3.33in the plan's hospitalization admission rate for medical assistance and MinnesotaCare
3.34enrollees, as determined by the commissioner. To earn the return of the withhold each
3.35year, the managed care plan or county-based purchasing plan must achieve a qualifying
3.36reduction of no less than five percent of the plan's hospital admission rate for medical
4.1assistance and MinnesotaCare enrollees, excluding enrollees in programs described in
4.2subdivisions 23 and 28, compared to the previous calendar year until the final performance
4.3target is reached. When measuring performance, the commissioner must consider the
4.4difference in health risk in a managed care or county-based purchasing plan's membership
4.5in the baseline year compared to the measurement year, and work with the managed care
4.6or county-based purchasing plan to account for differences that they agree are significant.
4.7The withheld funds must be returned no sooner than July 1 and no later than July
4.831 of the following calendar year if the managed care plan or county-based purchasing
4.9plan demonstrates to the satisfaction of the commissioner that this reduction in the
4.10hospitalization rate was achieved. The commissioner shall structure the withhold so that
4.11the commissioner returns a portion of the withheld funds in amounts commensurate with
4.12achieved reductions in utilization less than the targeted amount.
4.13The withhold described in this paragraph shall continue until there is a 25 percent
4.14reduction in the hospital admission rate compared to the hospital admission rates in
4.15calendar year 2011, as determined by the commissioner. The hospital admissions in this
4.16performance target do not include the admissions applicable to the subsequent hospital
4.17admission performance target under paragraph (i). Hospitals shall cooperate with the
4.18plans in meeting this performance target and shall accept payment withholds that may be
4.19returned to the hospitals if the performance target is achieved.
4.20(i) Effective for services rendered on or after January 1, 2012, the commissioner
4.21shall include as part of the performance targets described in paragraph (c) a reduction in
4.22the plan's hospitalization admission rates for subsequent hospitalizations within 30 days of
4.23a previous hospitalization of a patient regardless of the reason, for medical assistance and
4.24MinnesotaCare enrollees, as determined by the commissioner. To earn the return of the
4.25withhold each year, the managed care plan or county-based purchasing plan must achieve
4.26a qualifying reduction of the subsequent hospitalization rate for medical assistance and
4.27MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions 23
4.28and 28, of no less than five percent compared to the previous calendar year until the
4.29final performance target is reached.
4.30The withheld funds must be returned no sooner than July 1 and no later than July
4.3131 of the following calendar year if the managed care plan or county-based purchasing
4.32plan demonstrates to the satisfaction of the commissioner that a qualifying reduction in
4.33the subsequent hospitalization rate was achieved. The commissioner shall structure the
4.34withhold so that the commissioner returns a portion of the withheld funds in amounts
4.35commensurate with achieved reductions in utilization less than the targeted amount.
5.1The withhold described in this paragraph must continue for each consecutive
5.2contract period until the plan's subsequent hospitalization rate for medical assistance and
5.3MinnesotaCare enrollees, excluding enrollees in programs described in subdivisions 23
5.4and 28, is reduced by 25 percent of the plan's subsequent hospitalization rate for calendar
5.5year 2011. Hospitals shall cooperate with the plans in meeting this performance target and
5.6shall accept payment withholds that must be returned to the hospitals if the performance
5.7target is achieved.
5.8(j) Effective for services rendered on or after January 1, 2011, through December 31,
5.92011, the commissioner shall withhold 4.5 percent of managed care plan payments under
5.10this section and county-based purchasing plan payments under section
5.11prepaid medical assistance program. The withheld funds must be returned no sooner than
5.12July 1 and no later than July 31 of the following year. The commissioner may exclude
5.13special demonstration projects under subdivision 23.
5.14(k) Effective for services rendered on or after January 1, 2012, through December
5.1531, 2012, the commissioner shall withhold 4.5 percent of managed care plan payments
5.16under this section and county-based purchasing plan payments under section
5.18sooner than July 1 and no later than July 31 of the following year. The commissioner may
5.19exclude special demonstration projects under subdivision 23.
5.20(l) Effective for services rendered on or after January 1, 2013, through December 31,
5.212013, the commissioner shall withhold 4.5 percent of managed care plan payments under
5.22this section and county-based purchasing plan payments under section
5.23prepaid medical assistance program. The withheld funds must be returned no sooner than
5.24July 1 and no later than July 31 of the following year. The commissioner may exclude
5.25special demonstration projects under subdivision 23.
5.26(m) Effective for services rendered on or after January 1, 2014, the commissioner
5.27shall withhold three percent of managed care plan payments under this section and
5.28county-based purchasing plan payments under section
5.29assistance program. The withheld funds must be returned no sooner than July 1 and
5.30no later than July 31 of the following year. The commissioner may exclude special
5.31demonstration projects under subdivision 23.
5.32(n) A managed care plan or a county-based purchasing plan under section
5.34section that is reasonably expected to be returned.
6.1(o) Contracts between the commissioner and a prepaid health plan are exempt from
6.2the set-aside and preference provisions of section
6.3(a), and 7.
6.4(p) The return of the withhold under paragraphs (d), (f), and (j) to (m) is not subject
6.5to the requirements of paragraph (c).
