Purpose of the Bill

This legislative proposal seeks to establish a payment withhold policy tied to verification procedures within Minnesota's medical assistance programs. The goal is to ensure the accuracy of coverage information and incentivize managed care plans and county-based purchasing plans to meet specific performance and verification targets.

Main Provisions

• Capitation Payment Withhold: Starting January 1, 2026, a two percent withhold will be applied to the capitation payments made to managed care plans and county-based purchasing plans for each medical assistance enrollee. This withhold aims to encourage plans to verify enrollee coverage details accurately.

• Verification of Coverage: A new process requires managed care plans to submit a verification of coverage form, completed and signed by enrollees, by the end of February 2026. This form must include the enrollee’s name, address, and the chosen managed care or purchasing plan, with a signature affirming the information's accuracy.

• Performance Targets: Five percent of managed care plan payments will be withheld pending the achievement of quantifiable, measurable performance targets, which will aim to improve administrative services and manage healthcare spending effectively. These targets should be based on evidence-based research and will involve input from clinical experts and stakeholders.

• Documentation and Compliance: Managed care plans must use specific assessment, authorization, and billing processes in line with the Department of Human Services standards. Plans must also maintain current agreements with subcontractors for services charged to public health care programs.

Significant Changes to Existing Law

• An emphasis on compliance: Managed care contracts must now include stringent requirements for verifying enrollee details and meeting performance measures.
• Administrative oversight: The bill introduces a system to periodically update administrative measures used as performance targets to enhance efficiency and accountability.
• Consequences for non-compliance: If verification forms are not submitted on time, the withheld funds will not be returned, further payments for those enrollees will be stopped, and the enrollee will be disenrolled from medical assistance.

Relevant Terms

managed care plans, medical assistance, capitation payment, verification of coverage, county-based purchasing plans, performance targets, evidence-based research, subcontractors, capitation payment withhold, enrollee disenrollment.