Medical assistance capitation payment withhold related to verification of coverage established.

A bill for an act

relating to human services; establishing a medical assistance capitation payment

withhold related to verification of coverage; amending Minnesota Statutes 2024,

section 256B.69, subdivision 5a.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2024, section 256B.69, subdivision 5a, is amended to read:

Subd. 5a.

Managed care contracts.

(a) Managed care contracts under this section and

section
256L.12
shall be entered into or renewed on a calendar year basis. The commissioner

may issue separate contracts with requirements specific to services to medical assistance

recipients age 65 and older.

(b) A prepaid health plan providing covered health services for eligible persons pursuant

to chapters
256B
and
256L
is responsible for complying with the terms of its contract with

the commissioner. Requirements applicable to managed care programs under chapters
256B

and
256L
established after the effective date of a contract with the commissioner take effect

when the contract is next issued or renewed.

(c) The commissioner shall withhold five percent of managed care plan payments under

this section and county-based purchasing plan payments under section
256B.692
for the

prepaid medical assistance program pending completion of performance targets. Each

performance target must be quantifiable, objective, measurable, and reasonably attainable,

except in the case of a performance target based on a federal or state law or rule. Criteria

for assessment of each performance target must be outlined in writing prior to the contract

effective date. Clinical or utilization performance targets and their related criteria must

consider evidence-based research and reasonable interventions when available or applicable

to the populations served, and must be developed with input from external clinical experts

and stakeholders, including managed care plans, county-based purchasing plans, and

providers. The managed care or county-based purchasing plan must demonstrate, to the

commissioner's satisfaction, that the data submitted regarding attainment of the performance

target is accurate. The commissioner shall periodically change the administrative measures

used as performance targets in order to improve plan performance across a broader range

of administrative services. The performance targets must include measurement of plan

efforts to contain spending on health care services and administrative activities. The

commissioner may adopt plan-specific performance targets that take into account factors

affecting only one plan, including characteristics of the plan's enrollee population. The

withheld funds must be returned no sooner than July of the following year if performance

targets in the contract are achieved. The commissioner may exclude special demonstration

projects under subdivision 23.

(d) The commissioner shall require that managed care plans:

(1) use the assessment and authorization processes, forms, timelines, standards,

documentation, and data reporting requirements, protocols, billing processes, and policies

consistent with medical assistance fee-for-service or the Department of Human Services

contract requirements for all personal care assistance services under section
256B.0659
and

community first services and supports under section
256B.85
;

(2) by January 30 of each year that follows a rate increase for any aspect of services

under section
256B.0659
or
256B.85
, inform the commissioner and the chairs and ranking

minority members of the legislative committees with jurisdiction over rates determined

under section
256B.851
of the amount of the rate increase that is paid to each personal care

assistance provider agency with which the plan has a contract; and

(3) use a six-month timely filing standard and provide an exemption to the timely filing

timeliness for the resubmission of claims where there has been a denial, request for more

information, or system issue.

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(e) Effective for services rendered on or after January 1, 2013, through December 31,

2013, The commissioner shall withhold 4.5 percent of managed care plan payments under

this section and county-based purchasing plan payments under section
256B.692
for the

prepaid medical assistance program. The withheld funds must be returned no sooner than

July 1 and no later than July 31 of the following year. The commissioner may exclude

special demonstration projects under subdivision 23.

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(f) Effective for services rendered on or after January 1, 2014,
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(e)
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The commissioner

shall withhold three percent of managed care plan payments under this section and

county-based purchasing plan payments under section
256B.692
for the prepaid medical

assistance program. The withheld funds must be returned no sooner than July 1 and no later

than July 31 of the following year. The commissioner may exclude special demonstration

projects under subdivision 23.

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(g)
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(f)
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A managed care plan or a county-based purchasing plan under section
256B.692

may include as admitted assets under section
62D.044
any amount withheld under this

section that is reasonably expected to be returned.

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(h)
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(g)
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Contracts between the commissioner and a prepaid health plan are exempt from

the set-aside and preference provisions of section
16C.16, subdivisions 6
, paragraph (a),

and 7.

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(i)
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(h)
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The return of the withhold under
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paragraphs
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paragraph
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(e)
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and (f)
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is not subject

to the requirements of paragraph (c).

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(j)
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(i)
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Managed care plans and county-based purchasing plans shall maintain current and

fully executed agreements for all subcontractors, including bargaining groups, for

administrative services that are expensed to the state's public health care programs.

Subcontractor agreements determined to be material, as defined by the commissioner after

taking into account state contracting and relevant statutory requirements, must be in the

form of a written instrument or electronic document containing the elements of offer,

acceptance, consideration, payment terms, scope, duration of the contract, and how the

subcontractor services relate to state public health care programs. Upon request, the

commissioner shall have access to all subcontractor documentation under this paragraph.

Nothing in this paragraph shall allow release of information that is nonpublic data pursuant

to section
13.02
.

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(j) Effective for services provided on or after January 1, 2026, through December 31,

2026, the commissioner shall withhold two percent of the capitation payment provided to

managed care plans under this section and county-based purchasing plans under section

256B.692, for each medical assistance enrollee. The withheld funds must be returned no

sooner than July 1 and no later than July 31 of the following year for capitation payments

for enrollees for whom the plan submitted to the commissioner a verification of coverage

form completed and signed by the enrollee. The verification of coverage form must be

developed by the commissioner and made available to managed care and county-based

purchasing plans. The form must require the enrollee to provide the enrollee's name and

street address and the name of the managed care or county-based purchasing plan selected

by or assigned to the enrollee, and must include a signature block that allows the enrollee

to attest that the information provided is accurate. A plan must request that all enrollees

complete the verification of coverage form, and must submit all completed forms to the

commissioner by February 28, 2026. If a completed form for an enrollee is not received by

the commissioner by that date:

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(1) the commissioner shall not return funds to the plan withheld for that enrollee;

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(2) the commissioner shall cease making capitation payments to the plan for that enrollee,

effective for the April 2026 coverage month; and

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(3) the commissioner shall disenroll the enrollee from medical assistance, subject to any

enrollee appeal.

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