HF255

Purpose

The bill creates a PatientCentered Care program with the goal of better health outcomes and lower state health costs. It does this by paying health care providers directly to deliver services to Medical Assistance (MA) and MinnesotaCare enrollees, rather than paying through traditional managed care arrangements. It also allows counties to use a county-based purchasing option to participate in or form a new purchasing arrangement, which would administer payments under the program.

Main Provisions

• Direct provider payments

  • The state will pay licensed health care providers directly for all services to MA enrollees and MinnesotaCare enrollees.
  • Payments go to individual providers and clinics, not to hospital systems or large provider networks.
  • Providers will also be paid separately for drugs, immunizations, and vaccines.
  • Providers must bill the state or the county-based purchaser directly; the state and purchasers may not shift risk to providers or other entities.
  • The state shall not renew contracts with managed care plans or integrated health partnerships for MA and MinnesotaCare services.

• Care coordination

  • Primary care providers can be paid to coordinate care for MA and MinnesotaCare enrollees.
  • Enrollees may choose a primary care provider to act as their care coordinator.
  • Primary care physicians, nurses, and other qualified case management professionals can provide care coordination.
  • Clinics or counties providing care coordination receive a monthly fee per enrollee who uses the clinic for primary care.
  • Higher care coordination fees are set for clinics serving more people with factors that lead to health disparities.
  • The primary care provider oversees the enrollee’s overall health and coordinates with any case manager.
  • Community health workers at federally qualified health centers and other clinics may be paid to provide care coordination.

• Community outreach and support services

  • Grants to community health clinics and CBPs to hire community health workers, nurses, or social workers to do community outreach and deliver care coordination, especially for people who face mental illness, homelessness, or other barriers to care.
  • Clinics will help patients enroll in medical assistance.
  • Grants to collaborate with medical providers to reduce hospital readmissions, including discharge planning, medical respite, and transitional care for patients leaving facilities or mental health/chemical dependency programs.

• Enrollee support and access

  • The commissioner must maintain a hotline and a website to help enrollees locate providers.
  • A 24/7 nurse consultation helpline will be available.
  • The commissioner will contact enrollees who have not had preventive visits (based on claims data) to help them choose a primary care provider.
  • Counties with CBP may provide these services through DHS reimbursement.

• Provider standards and timing

  • The commissioner must ensure reimbursement rates are reasonable and fair, meet federal CMS requirements, and help prevent shortages in areas like mental health and dental services.
  • Reimbursement must be timely.
  • The commissioner should work with frontline providers to improve quality and reduce costs.

Significant Changes from Current Law

• Elimination of direct payments through managed care plans and integrated health partnerships for MA and MinnesotaCare; shift to direct payments to individual providers and clinics.
• Replacing or superseding existing MA/MinnesotaCare managed care contracts and integrated health partnerships with a direct payment and provider-based care coordination model.
• Introduction of a formal care coordination framework with monthly fees paid to clinics or providers.
• Expanded role for community health workers, CHCs, and CBPs in outreach, enrollment assistance, and discharge planning to reduce hospital readmissions.
• Greater emphasis on provider-level accountability for timely payments and adherence to CMS requirements; explicit avoidance of risk shifting to providers or purchaser entities.

Implementation and Oversight

• The Department of Human Services (the commissioner) administers payments, care coordination, outreach, and related services.
• Counties may participate in or form a CBP to administer parts of the program; if a county takes over, the CBP administers the program and payments.
• The bill repeals certain existing MA/MinnesotaCare service delivery structures (e.g., specific contracts with managed care plans and integrated partnerships) in favor of direct provider payments and the new coordination framework.

Potential Implications to Watch

• Access and care coordination quality may improve due to direct provider payments and a focus on primary care coordination.
• Providers may face changes in administrative processes, billing, and speed of reimbursement.
• The state and counties will need to manage the new funding streams, ensure CMS compliance, and monitor for unintended shifts in risk or costs.
• The emphasis on outreach and discharge planning could impact hospital readmissions and transitions of care.

Relevant Terms - PatientCentered Care program - direct payment / direct payments to health care providers - medical assistance (MA) - MinnesotaCare - county-based purchasing (CBP) - primary care provider / care coordination - clinics / provider-specific payments - drugs, immunizations, vaccines payments - no shifting of risk to providers - managed care plans (CMS-related requirements) - integrated health partnerships - care coordination fees - community health workers - federally qualified health centers - community outreach - discharge planning - medical respite - transitional care - hotline - nurse consultation helpline - claims data - enrollment assistance