High-risk provider types under medical assistance program integrity requirements establishment provision

A bill for an act

relating to human services; establishing program integrity requirements for high-risk

provider types under medical assistance; requiring a report; amending Minnesota

Statutes 2024, sections 142B.01, subdivision 8; 245A.02, subdivision 5a; 245D.081,

subdivision 3; 256B.0949, subdivision 17; Minnesota Statutes 2025 Supplement,

sections 256B.04, subdivision 21; 256B.0759, subdivision 4; 256B.0949,

subdivision 16; proposing coding for new law in Minnesota Statutes, chapter 256B.

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

Section 1.

Minnesota Statutes 2024, section 142B.01, subdivision 8, is amended to read:

Subd. 8.

Controlling individual.

(a) "Controlling individual" means an owner of a

program or service provider licensed under this chapter and the following individuals, if

applicable:

(1) each officer of the organization, including the chief executive officer and chief

financial officer;

(2) the individual designated as the authorized agent under section
142B.10, subdivision

1, paragraph (b);

(3) the individual designated as the compliance officer under section
deleted text begin
256B.04,
deleted text begin
subdivision
deleted text end

21, paragraph (g)
deleted text end
new text begin
256B.044, subdivision 7, paragraph (b)
new text end
;

(4) each managerial official whose responsibilities include the direction of the

management or policies of a program;

(5) the individual designated as the primary provider of care for a special family child

care program under section
142B.41, subdivision 4
, paragraph (d); and

(6) the president and treasurer of the board of directors of a nonprofit corporation.

(b) Controlling individual does not include:

(1) a bank, savings bank, trust company, savings association, credit union, industrial

loan and thrift company, investment banking firm, or insurance company unless the entity

operates a program directly or through a subsidiary;

(2) an individual who is a state or federal official, or state or federal employee, or a

member or employee of the governing body of a political subdivision of the state or federal

government that operates one or more programs, unless the individual is also an officer,

owner, or managerial official of the program; receives remuneration from the program; or

owns any of the beneficial interests not excluded in this subdivision;

(3) an individual who owns less than five percent of the outstanding common shares of

a corporation:

(i) whose securities are exempt under section
80A.45
, clause (6); or

(ii) whose transactions are exempt under section
80A.46
, clause (2);

(4) an individual who is a member of an organization exempt from taxation under section

290.05
, unless the individual is also an officer, owner, or managerial official of the program

or owns any of the beneficial interests not excluded in this subdivision. This clause does

not exclude from the definition of controlling individual an organization that is exempt from

taxation; or

(5) an employee stock ownership plan trust, or a participant or board member of an

employee stock ownership plan, unless the participant or board member is a controlling

individual according to paragraph (a).

(c) For purposes of this subdivision, "managerial official" means an individual who has

the decision-making authority related to the operation of the program, and the responsibility

for the ongoing management of or direction of the policies, services, or employees of the

program. A site director who has no ownership interest in the program is not considered to

be a managerial official for purposes of this definition.

Sec. 2.

Minnesota Statutes 2024, section 245A.02, subdivision 5a, is amended to read:

Subd. 5a.

Controlling individual.

(a) "Controlling individual" means an owner of a

program or service provider licensed under this chapter and the following individuals, if

applicable:

(1) each officer of the organization, including the chief executive officer and chief

financial officer;

(2) the individual designated as the authorized agent under section
245A.04, subdivision

1
, paragraph (b);

(3) the individual designated as the compliance officer under section
deleted text begin
256B.04, subdivision

21
, paragraph (g)
deleted text end
new text begin
256B.044, subdivision 7, paragraph (b)
new text end
;

(4) each managerial official whose responsibilities include the direction of the

management or policies of a program; and

(5) the president and treasurer of the board of directors of a nonprofit corporation.

(b) Controlling individual does not include:

(1) a bank, savings bank, trust company, savings association, credit union, industrial

loan and thrift company, investment banking firm, or insurance company unless the entity

operates a program directly or through a subsidiary;

(2) an individual who is a state or federal official, or state or federal employee, or a

member or employee of the governing body of a political subdivision of the state or federal

government that operates one or more programs, unless the individual is also an officer,

owner, or managerial official of the program, receives remuneration from the program, or

owns any of the beneficial interests not excluded in this subdivision;

(3) an individual who owns less than five percent of the outstanding common shares of

a corporation:

(i) whose securities are exempt under section
80A.45
, clause (6); or

(ii) whose transactions are exempt under section
80A.46
, clause (2);

(4) an individual who is a member of an organization exempt from taxation under section

290.05
, unless the individual is also an officer, owner, or managerial official of the program

or owns any of the beneficial interests not excluded in this subdivision. This clause does

not exclude from the definition of controlling individual an organization that is exempt from

taxation; or

(5) an employee stock ownership plan trust, or a participant or board member of an

employee stock ownership plan, unless the participant or board member is a controlling

individual according to paragraph (a).

(c) For purposes of this subdivision, "managerial official" means an individual who has

the decision-making authority related to the operation of the program, and the responsibility

for the ongoing management of or direction of the policies, services, or employees of the

program. A site director who has no ownership interest in the program is not considered to

be a managerial official for purposes of this definition.

Sec. 3.

Minnesota Statutes 2024, section 245D.081, subdivision 3, is amended to read:

Subd. 3.

Program management and oversight.

(a) The license holder must designate

a managerial staff person or persons to provide program management and oversight of the

services provided by the license holder. The designated manager is responsible for the

following:

(1) maintaining a current understanding of the licensing requirements sufficient to ensure

compliance throughout the program as identified in section
245A.04, subdivision
1, paragraph

(e), and when applicable, as identified in section
deleted text begin
256B.04, subdivision 21
, paragraph (g)
deleted text end
new text begin

256B.044, subdivision 7
new text end
;

(2) ensuring the duties of the designated coordinator are fulfilled according to the

requirements in subdivision 2;

(3) ensuring the program implements corrective action identified as necessary by the

program following review of incident and emergency reports according to the requirements

in section
245D.11, subdivision 2
, clause (7). An internal review of incident reports of

alleged or suspected maltreatment must be conducted according to the requirements in

section
245A.65, subdivision 1
, paragraph (b);

(4) evaluation of satisfaction of persons served by the program, the person's legal

representative, if any, and the case manager, with the service delivery and progress toward

accomplishing outcomes identified in sections
245D.07
and
245D.071
, and ensuring and

protecting each person's rights as identified in section
245D.04
;

(5) ensuring staff competency requirements are met according to the requirements in

section
245D.09, subdivision 3
, and ensuring staff orientation and training is provided

according to the requirements in section
245D.09, subdivisions 4
, 4a, and 5;

(6) ensuring corrective action is taken when ordered by the commissioner and that the

terms and conditions of the license and any variances are met; and

(7) evaluating the information identified in clauses (1) to (6) to develop, document, and

implement ongoing program improvements.

(b) The designated manager must be competent to perform the duties as required and

must minimally meet the education and training requirements identified in subdivision 2,

paragraph (b), and have a minimum of three years of supervisory level experience in a

program that provides care or education to vulnerable adults or children.

Sec. 4.

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

to read:

Subd. 21.

Provider enrollment.

deleted text begin
(a)
deleted text end
The commissioner shall enroll providers and conduct

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

E
new text begin
, and sections 256B.044 to 256B.0444
new text end
.

deleted text begin

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

deleted text end

deleted text begin

245C

deleted text end

deleted text begin

,

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).

deleted text end

deleted text begin

(b) The commissioner shall revalidate:

deleted text end

deleted text begin

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

deleted text end

deleted text begin

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

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

deleted text end

deleted text begin

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

deleted text end

deleted text begin

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

commissioner deems "high-risk" under this subdivision.

deleted text end

deleted text begin

(c) The commissioner shall conduct revalidation as follows:

deleted text end

deleted text begin

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

revalidation and a list of materials the provider must submit;

deleted text end

deleted text begin

(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

deleted text end

deleted text begin

(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.

deleted text end

deleted text begin

(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.

deleted text end

deleted text begin

(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.

deleted text end

deleted text begin

(f) If the commissioner or the Centers for Medicare and Medicaid Services 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.

deleted text end

deleted text begin

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

deleted text end

deleted text begin

245A

deleted text end

deleted text begin

,

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

deleted text end

deleted text begin

144G

deleted text end

deleted text begin

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:

deleted text end

deleted text begin

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

regulations and to prevent inappropriate claims submissions;

deleted text end

deleted text begin

(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);

deleted text end

deleted text begin

(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;

deleted text end

deleted text begin

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

regulations;

deleted text end

deleted text begin

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

laws or regulations; and

deleted text end

deleted text begin

(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.

deleted text end

deleted text begin

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 the Centers for Medicare and Medicaid Services.

deleted text end

deleted text begin

(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
.

deleted text end

deleted text begin

(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:

deleted text end

deleted text begin

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

to the Medicare program;

deleted text end

deleted text begin

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

review completed by the commissioner of health; and

deleted text end

deleted text begin

(3) serves primarily a pediatric population.

deleted text end

deleted text begin

(j) 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.

The commissioner shall publish in the Minnesota Health Care Program Provider Manual a

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

deleted text end

deleted text begin

14

deleted text end

deleted text begin

.

The commissioner's designations are not subject to administrative appeal.

deleted text end

deleted text begin

(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 the Centers for Medicare and Medicaid Services that a provider is designated

high-risk for fraud, waste, or abuse.

deleted text end

deleted text begin

(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.

deleted text end

deleted text begin

(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
.

deleted text end

deleted text begin

(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.

deleted text end

deleted text begin

(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
.

deleted text end

Sec. 5.

new text begin

[256B.044] PROVIDER ENROLLMENT.

new text end

new text begin

Subdivision 1.

new text end

new text begin

Designating categorical risk levels.

new text end

new text begin

(a) The commissioner must designate

provider types as "limited-risk," "moderate-risk," or "high-risk" based on the criteria and

standards used to designate Medicare providers in Code of Federal Regulations, title 42,

section 424.518. The commissioner must publish a list of provider types and designated

categorical risk levels in the Minnesota Health Care Program Provider Manual.

new text end

new text begin

(b) The list and criteria are not subject to the requirements of chapter 14, and section

14.386 does not apply.

new text end

new text begin

(c) The commissioner's designations are not subject to administrative appeal.

new text end

new text begin

Subd. 2.

new text end

new text begin

Service location enrollment.

new text end

new text begin

A provider must enroll each provider-controlled

location where direct services are provided.

new text end

new text begin

Subd. 3.

new text end

new text begin

Incomplete provider enrollment applications.

new text end

new text begin

The commissioner may deny

a provider's incomplete enrollment application if a provider fails to respond to the

commissioner's request for additional information within 60 days of the request.

new text end

new text begin

Subd. 4.

new text end

new text begin

Required background studies.

new text end

new text begin

(a) 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 applying for enrollment under

section 256B.04, subdivision 21. The background study requirement may be satisfied if the

commissioner conducted a fingerprint-based background study on the provider that included

a review of databases in section 245C.08, subdivision 1, paragraph (a), clauses (1) to (5).

new text end

new text begin

(b) As a condition of enrollment in medical assistance, the commissioner must 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 the Centers for Medicare and Medicaid Services (CMS) that a provider is

designated high-risk.

new text end

new text begin

Subd. 5.

new text end

new text begin

Surety bonds.

new text end

new text begin

(a) The commissioner may require a provider to purchase a

surety bond as a condition of initial enrollment, revalidation, reenrollment, reinstatement,

or continued enrollment if:

new text end

new text begin

(1) the provider fails to demonstrate financial viability;

new text end

new text begin

(2) the commissioner determines there is significant evidence of or potential for fraud

and abuse by the provider; or

new text end

new text begin

(3) the provider or category of providers is designated high-risk pursuant to subdivision

1 and Code of Federal Regulations, title 42, section 455.450.

new text end

new text begin

(b) 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.

new text end

new text begin

(c) This subdivision 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.

new text end

new text begin

Subd. 6.

new text end

new text begin

Required permission to conduct on-site inspection.

new text end

new text begin

As a condition of

enrollment in medical assistance, the commissioner shall require that a provider designated

moderate-risk or high-risk by CMS or the commissioner permit CMS, CMS's agents, or

CMS's designated contractors and the state agency, the state agency's agents, or the state

agency's designated contractors to conduct unannounced on-site inspections of any provider

location.

new text end

new text begin

Subd. 7.

new text end

new text begin

Compliance programs.

new text end

new text begin

(a) 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

CMS.

new text end

new text begin

(b) If an enrolled provider is required by the commissioner or by law to designate an

individual as the provider's compliance officer, the compliance officer must:

new text end

new text begin

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

regulations and to prevent inappropriate claims submissions;

new text end

new text begin

(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);

new text end

new text begin

(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;

new text end

new text begin

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

regulations;

new text end

new text begin

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

laws or regulations; and

new text end

new text begin

(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.

new text end

new text begin

Subd. 8.

new text end

new text begin

Correspondence and notification.

new text end

new text begin

The commissioner may deliver

correspondence and notifications, including notifications of termination and other actions,

electronically to a provider's MN-ITS mailbox. This subdivision does not apply to

correspondence and notifications related to background studies.

new text end

Sec. 6.

new text begin

[256B.0441] PROVIDER REVALIDATION.

new text end

new text begin

Subdivision 1.

new text end

new text begin

Provider revalidation schedule.

new text end

new text begin

The commissioner shall revalidate:

new text end

new text begin

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

new text end

new text begin

(2) each personal care assistance agency, community first services and supports (CFSS)

provider-agency, and CFSS financial management services provider at least once every

three years;

new text end

new text begin

(3) each early intensive developmental and behavioral intervention agency at least once

every three years; and

new text end

new text begin

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

commissioner deems high-risk under section 256B.044, subdivision 1.

new text end

new text begin

Subd. 2.

new text end

new text begin

Revalidation procedures.

new text end

new text begin

The commissioner shall conduct revalidation as

follows:

new text end

new text begin

(1) provide 30 days' notice of the revalidation due date, including instructions for

revalidation and a list of materials the provider must submit;

new text end

new text begin

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

of the deficiency within 14 days after the due date and allow the provider an additional 14

days from the notification date to comply; and

new text end

new text begin

(3) if a provider fails to remedy a deficiency within the 28-day time period, give 30 days'

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.

new text end

Sec. 7.

new text begin

[256B.0442] PROVIDER ENROLLMENT SUSPENSIONS AND

TERMINATIONS.

new text end

new text begin

Subdivision 1.

new text end

new text begin

Commissioner's general authority to suspend individual provider's

enrollment.

new text end

new text begin

(a) 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.

new text end

new text begin

(b) The commissioner's decision to suspend the provider is not subject to an administrative

appeal.

new text end

new text begin

Subd. 2.

new text end

new text begin

Commissioner's authority to revoke enrollment of certain providers for

lack of documentation.

new text end

new text begin

(a) 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 the

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.

new text end

new text begin

(b) Nothing in this subdivision limits the authority of the commissioner to sanction a

provider under section 256B.064.

new text end

new text begin

Subd. 3.

new text end

new text begin

Commissioner's duty to terminate provider enrollment.

new text end

new text begin

(a) Except as

provided in paragraph (b), the commissioner must 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.

new text end

new text begin

(b) The commissioner may exempt a rehabilitation agency from termination or denial

that would otherwise be required under paragraph (a) if the agency:

new text end

new text begin

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

to the Medicare program;

new text end

new text begin

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

review completed by the commissioner of health; and

new text end

new text begin

(3) serves primarily a pediatric population.

new text end

Sec. 8.

new text begin

[256B.0443] PROGRAM INTEGRITY FOR HIGH-RISK PROVIDERS.

new text end

new text begin

Subdivision 1.

new text end

new text begin

Provider enrollment moratorium.

new text end

new text begin

(a) If the commissioner or the Centers

for Medicare and Medicaid Services (CMS) designates a provider type as high-risk under

section 256B.044, subdivision 1, the commissioner must issue an enrollment moratorium

and stop accepting and processing applications from providers within that category within

15 days of the date of the designation. A moratorium issued under this section is effective

for a period of up to 24 months from the date the moratorium is issued.

new text end

new text begin

(b) Before ending the moratorium under this subdivision, the commissioner must

revalidate the enrollment of each provider within the affected category in accordance with

the revalidation procedures under section 256B.0441, subdivision 2.

new text end

new text begin

Subd. 2.

new text end

new text begin

Prepayment review.

new text end

new text begin

(a) If the commissioner or CMS designates a provider

type as high-risk under section 256B.044, subdivision 1, the commissioner must establish

prepayment review of fee-for-service claims submitted by providers within that category

within 15 days of the date of the designation. The prepayment review is effective for a

period of up to 24 months from the date prepayment review is established.

new text end

new text begin

(b) Prepayment review under this subdivision must comply with the timely processing

of claims requirements under Code of Federal Regulations, title 42, section 447.45.

new text end

new text begin

(c) All providers, except the Indian Health Service, are subject to prepayment review

under this subdivision for any fee-for-service claim submitted to the commissioner for a

covered service that is designated high-risk by the commissioner or CMS.

new text end

new text begin

(d) Before ending prepayment review under this subdivision, the commissioner must

review all fee-for-service claims submitted by providers subject to the prepayment review

under paragraph (a) in the 24 months preceding the date the provider type was designated

high-risk.

new text end

new text begin

Subd. 3.

new text end

new text begin

Commissioner's authority to withhold payments.

new text end

new text begin

(a) If the commissioner

or CMS designates a provider type as high-risk under section 256B.044, subdivision 1, the

commissioner may withhold payment from providers within that category upon initial

enrollment for a 90-day period.

new text end

new text begin

(b) The withholding for each provider must begin on the date of the first submission of

a claim.

new text end

new text begin

Subd. 4.

new text end

new text begin

Continued enrollment of new clients.

new text end

new text begin

Nothing in this section prohibits an

enrolled provider within the affected category from enrolling new clients or beneficiaries

during the period of the moratorium, prepayment review, or payment withholding under

this section.

new text end

new text begin

Subd. 5.

new text end

new text begin

Notice.

new text end

new text begin

At least ten days prior to issuing a moratorium or establishing

prepayment review under this section, the commissioner must notify enrolled providers

within the affected category and the chairs and ranking minority members of the legislative

committees with jurisdiction over health and human services about the actions the

commissioner plans to take under this section. The notice must:

new text end

new text begin

(1) include a list of provider types or covered services to which the moratorium or

prepayment review applies;

new text end

new text begin

(2) provide a general explanation for the basis of the high-risk designation; and

new text end

new text begin

(3) identify the start dates and anticipated durations of the provider enrollment moratorium

and the prepayment review.

new text end

new text begin

Subd. 6.

new text end

new text begin

Report to legislature.

new text end

new text begin

Within 60 days of ending a provider enrollment

moratorium or prepayment review under this section, the commissioner must submit a report

to the chairs and ranking minority members of the legislative committees with jurisdiction

over health and human services. The report must include, at a minimum:

new text end

new text begin

(1) a summary of any sanctions imposed under section 256B.064 on any providers subject

to the moratorium or prepayment review; and

new text end

new text begin

(2) recommendations for modifying or terminating the provision of covered services

deemed high-risk or delivered by provider types subject to the moratorium or prepayment

review.

new text end

Sec. 9.

new text begin

[256B.0444] ADDITIONAL PROVIDER ENROLLMENT REQUIREMENTS

FOR SPECIFIC PROVIDER TYPES.

new text end

new text begin

Subdivision 1.

new text end

new text begin

Durable medical equipment provider or supplier.

new text end

new text begin

(a) For purposes of

this subdivision, "durable medical equipment provider or supplier" means a medical supplier

that can purchase medical equipment or supplies for sale or rent to the general public and

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

for sale or rent.

new text end

new text begin

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

medical equipment, prosthetics, orthotics, and supplies medical suppliers meeting the durable

medical equipment provider or supplier definition in paragraph (a), operating in Minnesota,

and receiving Medicaid money must purchase a surety bond that is annually renewed,

designates the state agency as the obligee, and is submitted in a form approved by the

commissioner. For purposes of this paragraph, 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.

new text end

new text begin

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

or suppliers defined in paragraph (a) 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.

new text end

new text begin

Subd. 2.

new text end

new text begin

Providers licensed by the commissioner of human services.

new text end

new text begin

An enrolled

provider that is also licensed by the commissioner under chapter 245A must designate an

individual as the licensee's compliance officer under section 256B.044, subdivision 7,

paragraph (b).

new text end

new text begin

Subd. 3.

new text end

new text begin

Providers licensed by the commissioner of health.

new text end

new text begin

An enrolled provider that

is also licensed by the commissioner of health as a home care provider under chapter 144A

with a home and community-based services designation under section 144A.484 on the

home care license, or as an assisted living facility under chapter 144G, must designate an

individual as the licensee's compliance officer under section 256B.044, subdivision 7,

paragraph (b).

new text end

Sec. 10.

Minnesota Statutes 2025 Supplement, section 256B.0759, subdivision 4, is

amended to read:

Subd. 4.

Provider payment rates.

(a) Payment rates for participating providers must

be increased for services provided to medical assistance enrollees. To receive a rate increase,

participating providers must meet demonstration project requirements and provide evidence

of formal referral arrangements with providers delivering step-up or step-down levels of

care. Providers that have enrolled in the demonstration project but have not met the provider

standards under subdivision 3 as of July 1, 2022, are not eligible for a rate increase under

this subdivision until the date that the provider meets the provider standards in subdivision

3. Services provided from July 1, 2022, to the date that the provider meets the provider

standards under subdivision 3 shall be reimbursed at rates according to section
254B.0505,

subdivision 1
. Rate increases paid under this subdivision to a provider for services provided

between July 1, 2021, and July 1, 2022, are not subject to recoupment when the provider

is taking meaningful steps to meet demonstration project requirements that are not otherwise

required by law, and the provider provides documentation to the commissioner, upon request,

of the steps being taken.

(b) The commissioner may temporarily suspend payments to the provider according to

section
deleted text begin
256B.04, subdivision 21
, paragraph (d)
deleted text end
new text begin
256B.0442, subdivision 1
new text end
, if the provider

does not meet the requirements in paragraph (a). Payments withheld from the provider must

be made once the commissioner determines that the requirements in paragraph (a) are met.

(c) For outpatient individual and group substance use disorder services under section

254B.0505, subdivision 1
, clause (1), and adolescent treatment programs that are licensed

as outpatient treatment programs according to sections
245G.01
to
245G.18
, provided on

or after January 1, 2021, payment rates must be increased by 20 percent over the rates in

effect on December 31, 2020.

(d) Effective January 1, 2021, and contingent on annual federal approval, managed care

plans and county-based purchasing plans must reimburse providers of the substance use

disorder services meeting the criteria described in paragraph (a) who are employed by or

under contract with the plan an amount that is at least equal to the fee-for-service base rate

payment for the substance use disorder services described in paragraph (c). The commissioner

must monitor the effect of this requirement on the rate of access to substance use disorder

services and residential substance use disorder rates. Capitation rates paid to managed care

organizations and county-based purchasing plans must reflect the impact of this requirement.

This paragraph expires if federal approval is not received at any time as required under this

paragraph.

(e) Effective July 1, 2021, contracts between managed care plans and county-based

purchasing plans and providers to whom paragraph (d) applies must allow recovery of

payments from those providers if, for any contract year, federal approval for the provisions

of paragraph (d) is not received, and capitation rates are adjusted as a result. Payment

recoveries must not exceed the amount equal to any decrease in rates that results from this

provision.

(f) For substance use disorder services with medications for opioid use disorder under

section
254B.0505, subdivision 1
, clause (7), provided on or after January 1, 2021, payment

rates must be increased by 20 percent over the rates in effect on December 31, 2020. Upon

implementation of new rates according to section
254B.121
, the 20 percent increase will

no longer apply.

Sec. 11.

Minnesota Statutes 2025 Supplement, section 256B.0949, subdivision 16, is

amended to read:

Subd. 16.

Agency duties.

(a) An agency delivering an EIDBI service under this section

must:

(1) enroll as a medical assistance Minnesota health care program provider according to

Minnesota Rules, part
9505.0195
, and
deleted text begin
section
256B.04, subdivision 21
deleted text end
new text begin
sections 256B.044

to 256B.0444
new text end
, and meet all applicable provider standards and requirements;

(2) designate an individual as the agency's compliance officer who must perform the

duties described in section
deleted text begin
256B.04, subdivision 21
, paragraph (g)
deleted text end
new text begin
256B.044, subdivision

7, paragraph (b)
new text end
;

(3) demonstrate compliance with federal and state laws for the delivery of and billing

for EIDBI service;

(4) verify and maintain records of a service provided to the person or the person's legal

representative as required under Minnesota Rules, parts
9505.2175
and
9505.2197
;

(5) demonstrate that while enrolled or seeking enrollment as a Minnesota health care

program provider the agency did not have a lead agency contract or provider agreement

discontinued because of a conviction of fraud; or did not have an owner, board member, or

manager fail a state or federal criminal background check or appear on the list of excluded

individuals or entities maintained by the federal Department of Human Services Office of

Inspector General;

(6) have established business practices including written policies and procedures, internal

controls, and a system that demonstrates the organization's ability to deliver quality EIDBI

services, appropriately submit claims, conduct required staff training, document staff

qualifications, document service activities, and document service quality;

(7) have an office located in Minnesota or a border state;

(8) initiate a background study as required under subdivision 16a;

(9) report maltreatment according to section
626.557
and chapter 260E;

(10) comply with any data requests consistent with the Minnesota Government Data

Practices Act, sections
256B.064
and
256B.27
;

(11) provide training for all agency staff on the requirements and responsibilities listed

in the Maltreatment of Minors Act, chapter 260E, and the Vulnerable Adult Protection Act,

section
626.557
, including mandated and voluntary reporting, nonretaliation, and the agency's

policy for all staff on how to report suspected abuse and neglect;

(12) have a written policy to resolve issues collaboratively with the person and the

person's legal representative when possible. The policy must include a timeline for when

the person and the person's legal representative will be notified about issues that arise in

the provision of services;

(13) provide the person's legal representative with prompt notification if the person is

injured while being served by the agency. An incident report must be completed by the

agency staff member in charge of the person. A copy of all incident and injury reports must

remain on file at the agency for at least five years from the report of the incident;

(14) before starting a service, provide the person or the person's legal representative a

description of the treatment modality that the person shall receive, including the staffing

certification levels and training of the staff who shall provide a treatment;

(15) provide clinical supervision for a minimum of one hour for every 16 hours of direct

treatment per person, unless otherwise authorized in the person's individual treatment plan;

and

(16) provide required EIDBI intervention observation and direction at least once per

month. Notwithstanding subdivision 13, paragraph (l), required EIDBI intervention

observation and direction under this clause may be conducted via telehealth provided that

no more than two consecutive monthly required EIDBI intervention observation and direction

sessions under this clause are conducted via telehealth.

(b) Upon request of the commissioner, an agency delivering services under this section

must:

(1) identify the agency's controlling individuals, as defined under section
245A.02,

subdivision 5a
;

(2) provide disclosures of the use of billing agencies and other consultants who do not

provide EIDBI services; and

(3) provide copies of any contracts with consultants or independent contractors who do

not provide EIDBI services, including hours contracted and responsibilities.

(c) When delivering the ITP, and annually thereafter, an agency must provide the person

or the person's legal representative with:

(1) a written copy and a verbal explanation of the person's or person's legal

representative's rights and the agency's responsibilities;

(2) documentation in the person's file the date that the person or the person's legal

representative received a copy and explanation of the person's or person's legal

representative's rights and the agency's responsibilities; and

(3) reasonable accommodations to provide the information in another format or language

as needed to facilitate understanding of the person's or person's legal representative's rights

and the agency's responsibilities.

Sec. 12.

Minnesota Statutes 2024, section 256B.0949, subdivision 17, is amended to read:

Subd. 17.

Provider shortage; authority for exceptions.

(a) In consultation with the

Early Intensive Developmental and Behavioral Intervention Advisory Council and

stakeholders, including agencies, professionals, parents of people with ASD or a related

condition, and advocacy organizations, the commissioner shall determine if a shortage of

EIDBI providers exists. For the purposes of this subdivision, "shortage of EIDBI providers"

means a lack of availability of providers who meet the EIDBI provider qualification

requirements under subdivision 15 that results in the delay of access to timely services under

this section, or that significantly impairs the ability of a provider agency to have sufficient

providers to meet the requirements of this section. The commissioner shall consider

geographic factors when determining the prevalence of a shortage. The commissioner may

determine that a shortage exists only in a specific region of the state, multiple regions of

the state, or statewide. The commissioner shall also consider the availability of various types

of treatment modalities covered under this section.

(b) The commissioner, in consultation with the Early Intensive Developmental and

Behavioral Intervention Advisory Council and stakeholders, must establish processes and

criteria for granting an exception under this paragraph. The commissioner may grant an

exception only if the exception would not compromise a person's safety and not diminish

the effectiveness of the treatment. The commissioner may establish an expiration date for

an exception granted under this paragraph. The commissioner may grant an exception for

the following:

(1) EIDBI provider qualifications under this section;

(2) medical assistance provider enrollment requirements under
deleted text begin
section
256B.04
,

subdivision 21
deleted text end
new text begin
sections 256B.044 to 256B.0444
new text end
; or

(3) EIDBI provider or agency standards or requirements.

(c) If the commissioner, in consultation with the Early Intensive Developmental and

Behavioral Intervention Advisory Council and stakeholders, determines that a shortage no

longer exists, the commissioner must submit a notice that a shortage no longer exists to the

chairs and ranking minority members of the senate and the house of representatives

committees with jurisdiction over health and human services. The commissioner must post

the notice for public comment for 30 days. The commissioner shall consider public comments

before submitting to the legislature a request to end the shortage declaration. The

commissioner shall not declare the shortage of EIDBI providers ended without direction

from the legislature to declare it ended.