HF4620

Purpose

This bill seeks to increase and adjust reimbursement rates for Medical Assistance (Medicaid) physician and professional services, specifically for complex outpatient visits. It modifies Minnesota Statutes 2025 Supplement section 256B.76 subdivision 1 to update how outpatient and related services are paid, with a long series of rate changes dating back to the 1990s and extending into 2027.

Main Provisions

• Reimbursement framework for physician and professional services:
  • Establishes a tiered method for paying different categories of outpatient services, using the lower of submitted charges or certain percentage increases above historical bases (initially set in 1992 and tied to earlier baseline rates).
  • Requires conversion of older base rates to ensure overall increases match the intended adjustments, with specific exclusions for home health agency rates.
• Multi-year rate adjustments:
  • 2000: 3% increase over the prior rates (for most physician/professional services; exceptions for home health and family planning).
  • 2009–2010: Overall rate reductions (5%), with a larger 6.5% reduction specifically for MA and GAMC during 7/1/2009–6/30/2010; certain visits and providers are exempt from these reductions (e.g., office/outpatient visits, preventive and family planning visits billed by certain clinicians; exclusions for FQHCs, rural health centers, and IHS).
  • 2010: An additional 7% reduction on top of the 5% reduction, with carve-outs for physical/occupational therapy and speech pathology services; no reduction for physician services billed by psychiatrists or nurse practitioners with mental health specialization.
  • 2011–2013: A 3% reduction (not applying to physical/occupational therapy and speech pathology and related services).
  • 2014: A 5% increase in rates (not applicable to FQHCs, rural health centers, or IHS); no adjustments to managed care plans to reflect this increase.
  • 2015: A 90% increase for hospital-provided physical therapy, occupational therapy, and speech pathology services meeting specified hospital criteria (not mirrored in managed care payments).
• Special programs and other provisions:
  • EIDBI (Early Intensive Developmental and Behavioral Intervention): Prior rate structures do not apply to EIDBI benefits described in the relevant statute.
  • Newborn screening: The commissioner can reimburse providers for costs to pay the newborn screening fee for MA enrollees when collected outside an inpatient hospital and not covered by another payment source.
  • 2027 adjustment for chronic pain E/M visits: Beginning 1/1/2027, outpatient evaluation and management visits for chronic and intractable pain that include HCPCS code G2211 will be increased by 10% above the December 31, 2026 rates. Beginning 1/1/2027, capitation payments to managed care plans and county-based purchasing plans will be increased to reflect this rate change.
• Administrative and payer scope:
  • The bill affects physician and professional services broadly, with specific references to managed care plans and county-based purchasing plans under Minnesota statutes.
  • Certain categories (FQHCs, rural health centers, IHS, and specified primary care practice types) are repeatedly exempt from particular reductions.
  • The base and adjustments involve long-standing references to historical rates and baselines (e.g., 1992, 1989, 1982 percentiles) to calculate current payments.

Notable Changes to Existing Law

• Repeats and revises a long, historically layered framework for how outpatient physician and professional services are reimbursed under MA, including both reductions and increases across multiple years.
• Introduces a significant 2027 adjustment tied to chronic pain management E/M visits with a specific HCPCS code (G2211) and ensures capitation payments to managed care/purchasing plans reflect this increase.
• Expands reimbursements for newborn screening costs under certain conditions.
• Maintains several exemptions from rate reductions for FQHCs, rural health centers, Indian Health Services, and specific primary care settings.
• Aligns managed care and county-based purchasing plans with certain reductions and increases described in the bill.

Implementation Details and Effective Dates

• Many changes are tied to specific effective dates (e.g., 1992, 2000, 2009/2010, 2011–2013, 2014, 2015, and 2027).
• Some provisions apply only to certain settings (e.g., outpatient visits vs. home health, family planning, hospital-based services).
• The section outlines that some rate adjustments are not applied to certain providers or settings, and that managed care and county-based purchasing plans may be required to reflect the described changes.

Likely Impacts

• Providers: Potentially higher or lower reimbursements in various years, depending on service type and setting.
• Hospitals and therapy services: Notable enhancement in 2015 for hospital-based PT/OT/SLP, with selective applicability.
• Newborn screening: Possible reimbursement for costs associated with outside-hospital newborn screening sample collection.
• Chronic pain care: A targeted 2027 increase aimed at outpatient chronic pain E/M visits with a specific coding addon, affecting both billing and capitation payments.

Relevant Terms - Medical Assistance (MA) - Medicaid - Minnesota Statutes 256B.76 subdivision 1 - Physician and professional services - Reimbursement rates - Outpatient visits / office and other outpatient services - Complex outpatient visits - Home health agency services - Family planning agency services - Federally Qualified Health Centers (FQHCs) - Rural health centers - Indian Health Services (IHS) - Managed care plans - County-based purchasing plans - 256B.69, 256B.692, 256L.12 (statutory references) - EIDBI (Early Intensive Developmental and Behavioral Intervention) - Newborn screening costs (heritable and congenital disorders) - HCPCS addon code G2211 - Outpatient evaluation and management (E/M) visits - Chronic and intractable pain - 90 percent increase for hospital-based PT/OT/SLP (section 62Q.19 criteria)