Site visits for all enrolled medical assistance providers required, and medical assistance provider enrollment fees for provider types not previously subject to mandatory site visits established.

A bill for an act

relating to human services; requiring site visits for all enrolled medical assistance

providers; establishing medical assistance provider enrollment fees for provider

types not previously subject to mandatory site visits; amending Minnesota Statutes

2024, section 256B.04, subdivision 22; Minnesota Statutes 2025 Supplement,

section 256B.04, subdivision 21.

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

Section 1.

Minnesota Statutes 2025 Supplement, section 256B.04, subdivision 21, is

amended to read:

Subd. 21.

Provider enrollment.

(a) The commissioner shall enroll providers and conduct

screening activities as required by Code of Federal Regulations, title 42, section 455, subpart

E. A provider must enroll each provider-controlled location where direct services are

provided. The commissioner may deny a provider's incomplete application if a provider

fails to respond to the commissioner's request for additional information within 60 days of

the request. The commissioner must conduct a background study under chapter 245C,

including a review of databases in section
245C.08, subdivision 1
, paragraph (a), clauses

(1) to (5), for a provider described in this paragraph. The background study requirement

may be satisfied if the commissioner conducted a fingerprint-based background study on

the provider that includes a review of databases in section
245C.08, subdivision 1
, paragraph

(a), clauses (1) to (5).

(b) The commissioner shall revalidate:

(1) each provider under this subdivision at least once every five years;

(2) each personal care assistance agency, CFSS provider-agency, and CFSS financial

management services provider under this subdivision at least once every three years;

(3) each EIDBI agency under this subdivision at least once every three years; and

(4) at the commissioner's discretion, any medical-assistance-only provider type the

commissioner deems "high-risk" under this subdivision.

(c) The commissioner shall conduct revalidation as follows:

(1) provide 30-day notice of the revalidation due date including instructions for

revalidation and a list of materials the provider must submit;

(2) if a provider fails to submit all required materials by the due date, notify the provider

of the deficiency within 30 days after the due date and allow the provider an additional 30

days from the notification date to comply; and

(3) if a provider fails to remedy a deficiency within the 30-day time period, give 60-day

notice of termination and immediately suspend the provider's ability to bill. The provider

does not have the right to appeal suspension of ability to bill.

(d) If a provider fails to comply with any individual provider requirement or condition

of participation, the commissioner may suspend the provider's ability to bill until the provider

comes into compliance. The commissioner's decision to suspend the provider is not subject

to an administrative appeal.

(e) Correspondence and notifications, including notifications of termination and other

actions, may be delivered electronically to a provider's MN-ITS mailbox. This paragraph

does not apply to correspondences and notifications related to background studies.

(f) If the commissioner or the Centers for Medicare and Medicaid Services
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(CMS)
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determines that a provider is designated "high-risk," the commissioner may withhold payment

from providers within that category upon initial enrollment for a 90-day period. The

withholding for each provider must begin on the date of the first submission of a claim.

(g) An enrolled provider that is also licensed by the commissioner under chapter 245A,

is licensed as a home care provider by the Department of Health under chapter 144A, or is

licensed as an assisted living facility under chapter 144G and has a home and

community-based services designation on the home care license under section
144A.484
,

must designate an individual as the entity's compliance officer. The compliance officer

must:

(1) develop policies and procedures to assure adherence to medical assistance laws and

regulations and to prevent inappropriate claims submissions;

(2) train the employees of the provider entity, and any agents or subcontractors of the

provider entity including billers, on the policies and procedures under clause (1);

(3) respond to allegations of improper conduct related to the provision or billing of

medical assistance services, and implement action to remediate any resulting problems;

(4) use evaluation techniques to monitor compliance with medical assistance laws and

regulations;

(5) promptly report to the commissioner any identified violations of medical assistance

laws or regulations; and

(6) within 60 days of discovery by the provider of a medical assistance reimbursement

overpayment, report the overpayment to the commissioner and make arrangements with

the commissioner for the commissioner's recovery of the overpayment.

The commissioner may require, as a condition of enrollment in medical assistance, that a

provider within a particular industry sector or category establish a compliance program that

contains the core elements established by
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the Centers for Medicare and Medicaid Services
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CMS
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.

(h) The commissioner may revoke the enrollment of an ordering or rendering provider

for a period of not more than one year, if the provider fails to maintain and, upon request

from the commissioner, provide access to documentation relating to written orders or requests

for payment for durable medical equipment, certifications for home health services, or

referrals for other items or services written or ordered by such provider, when the

commissioner has identified a pattern of a lack of documentation. A pattern means a failure

to maintain documentation or provide access to documentation on more than one occasion.

Nothing in this paragraph limits the authority of the commissioner to sanction a provider

under the provisions of section
256B.064
.

(i) The commissioner shall terminate or deny the enrollment of any individual or entity

if the individual or entity has been terminated from participation in Medicare or under the

Medicaid program or Children's Health Insurance Program of any other state. The

commissioner may exempt a rehabilitation agency from termination or denial that would

otherwise be required under this paragraph, if the agency:

(1) is unable to retain Medicare certification and enrollment solely due to a lack of billing

to the Medicare program;

(2) meets all other applicable Medicare certification requirements based on an on-site

review completed by the commissioner of health; and

(3) serves primarily a pediatric population.

(j)
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As a condition of enrollment in medical assistance, the commissioner shall require

that a provider designated "moderate" or "high-risk" by the Centers for Medicare and

Medicaid Services or the commissioner permit the Centers for Medicare and Medicaid

Services, its agents, or its designated contractors and the state agency, its agents, or its

designated contractors to conduct unannounced on-site inspections of any provider location.
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The commissioner shall publish in the Minnesota Health Care Program Provider Manual a

list of provider types designated "limited," "moderate," or "high-risk
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,
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"
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by CMS or by the

commissioner
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based on the criteria and standards used to designate Medicare providers in

Code of Federal Regulations, title 42, section 424.518. The list and criteria are not subject

to the requirements of chapter 14. The commissioner's designations are not subject to

administrative appeal.

(k) As a condition of enrollment in medical assistance, the commissioner shall require

that a high-risk provider, or a person with a direct or indirect ownership interest in the

provider of five percent or higher, consent to criminal background checks, including

fingerprinting, when required to do so under state law or by a determination by the

commissioner or
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the Centers for Medicare and Medicaid Services
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CMS
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that a provider is

designated high-risk for fraud, waste, or abuse.

(l)(1) Upon initial enrollment, reenrollment, and notification of revalidation, all durable

medical equipment, prosthetics, orthotics, and supplies (DMEPOS) medical suppliers

meeting the durable medical equipment provider and supplier definition in clause (3),

operating in Minnesota and receiving Medicaid funds must purchase a surety bond that is

annually renewed and designates the Minnesota Department of Human Services as the

obligee, and must be submitted in a form approved by the commissioner. For purposes of

this clause, the following medical suppliers are not required to obtain a surety bond: a

federally qualified health center, a home health agency, the Indian Health Service, a

pharmacy, and a rural health clinic.

(2) At the time of initial enrollment or reenrollment, durable medical equipment providers

and suppliers defined in clause (3) must purchase a surety bond of $50,000. If a revalidating

provider's Medicaid revenue in the previous calendar year is up to and including $300,000,

the provider agency must purchase a surety bond of $50,000. If a revalidating provider's

Medicaid revenue in the previous calendar year is over $300,000, the provider agency must

purchase a surety bond of $100,000. The surety bond must allow for recovery of costs and

fees in pursuing a claim on the bond. Any action to obtain monetary recovery or sanctions

from a surety bond must occur within six years from the date the debt is affirmed by a final

agency decision. An agency decision is final when the right to appeal the debt has been

exhausted or the time to appeal has expired under section
256B.064
.

(3) "Durable medical equipment provider or supplier" means a medical supplier that can

purchase medical equipment or supplies for sale or rental to the general public and is able

to perform or arrange for necessary repairs to and maintenance of equipment offered for

sale or rental.

(m) The Department of Human Services may require a provider to purchase a surety

bond as a condition of initial enrollment, reenrollment, reinstatement, or continued enrollment

if: (1) the provider fails to demonstrate financial viability, (2) the department determines

there is significant evidence of or potential for fraud and abuse by the provider, or (3) the

provider or category of providers is designated high-risk pursuant to paragraph (f) and as

per Code of Federal Regulations, title 42, section 455.450. The surety bond must be in an

amount of $100,000 or ten percent of the provider's payments from Medicaid during the

immediately preceding 12 months, whichever is greater. The surety bond must name the

Department of Human Services as an obligee and must allow for recovery of costs and fees

in pursuing a claim on the bond. This paragraph does not apply if the provider currently

maintains a surety bond under the requirements in section
256B.051
,
256B.0659
,
256B.0701
,

or
256B.85
.

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(n) As a condition of enrollment in medical assistance, a provider must permit CMS,

CMS's agents, or CMS's designated contractors and the commissioner, the commissioner's

agents, or the commissioner's designated contractors to conduct unannounced on-site

inspections of any provider location. Consistent with the commissioner's authority under

Code of Federal Regulations, title 42, section 455.452, the commissioner must conduct

unannounced on-site inspections of all provider locations prior to enrollment, prior to

re-enrollment, and prior to revalidation.

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Sec. 2.

Minnesota Statutes 2024, section 256B.04, subdivision 22, is amended to read:

Subd. 22.

Application fee.

(a) The commissioner must collect and retain
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federally

required
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nonrefundable application fees to pay for provider screening activities in accordance

with
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subdivision 21 and
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Code of Federal Regulations, title 42, section 455, subpart E. The

enrollment application must be made under the procedures specified by the commissioner,

in the form specified by the commissioner, and accompanied by the fee described in

paragraph (b), or a request for a hardship exception as described in the specified procedures.

The fees must be deposited in the provider screening account in the special revenue fund.

Amounts in the provider screening account are appropriated to the commissioner for costs

associated with the provider screening activities required in
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subdivision 21 and
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Code of

Federal Regulations, title 42, section 455, subpart E.

(b) The application fee under this subdivision is $532 for the calendar year 2013. For

calendar year 2014 and subsequent years, the fee:

(1) is adjusted by the percentage change to the Consumer Price Index for all urban

consumers, United States city average, for the 12-month period ending with June of the

previous year. The resulting fee must be announced in the Federal Register;

(2) is effective from January 1 to December 31 of a calendar year;

(3) is required on the submission of an initial application, an application to establish a

new practice location, an application for reenrollment when the provider is not enrolled at

the time of application of reenrollment, or at revalidation
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when required by federal regulation
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;

and

(4) must be in the amount in effect for the calendar year during which the application

for enrollment, new practice location, or reenrollment is being submitted.

(c) The fee under this subdivision cannot be charged to:

(1) providers who are enrolled in Medicare or who provide documentation of payment

of the fee to, and enrollment with, another state, unless the commissioner is required to

rescreen the provider;
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and
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(2) providers who are enrolled but are required to submit new applications for purposes

of reenrollment
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;
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.
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(3) a provider who enrolls as an individual; and

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(4) group practices and clinics that bill on behalf of individually enrolled providers

within the practice who have reassigned their billing privileges to the group practice or

clinic.

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