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SF3115 (Legislative Session 94 (2025-2026))

Medical assistance capitation payment withhold related to verification of coverage establishment provision

Related bill: HF2604

AI Generated Summary

Purpose of the Bill

This bill aims to modify the existing framework for medical assistance payments in Minnesota, specifically focusing on managed care and county-based purchasing plans. It introduces a new measure to ensure that coverage for medical assistance enrollees is verified. By doing so, it seeks to improve accuracy in enrollment and payment distribution.

Main Provisions

  • Withholding Payments: The bill establishes a practice of withholding a portion of capitation payments (a set amount paid per enrollee) from managed care plans until certain performance criteria are met. This is to ensure that the plans meet specific targets related to healthcare services and administrative activities.

  • Verification of Coverage: Managed care plans are required to have medical assistance enrollees complete a verification of coverage form. This form is necessary to attest to the accuracy of the enrollee's information and their choice of a managed care plan.

  • Payment Return Conditions: Withheld funds will only be returned to managed care plans if they meet performance targets, including the submission of completed verification forms by enrollees.

  • Disenrollment for Non-Verification: If an enrollee's verification form is not submitted by the stipulated deadline, the corresponding funds will not be returned to the plan, capitation payments will cease for that enrollee, and the enrollee may be disenrolled from medical assistance.

Significant Changes to Existing Law

  • Performance Evaluation: Introduces new performance targets for managed care plans, which are based on evidence and developed with external input. These targets address efficiency in spending and administrative functions.

  • Caps on Payment Withholds: Adjusts payment withholds to a set percentage, decreasing previously higher withhold percentages to a standard two percent for certain services rendered within specified periods.

  • Mandatory Documentation: Managed care plans must now maintain comprehensive agreements with all subcontractors. These contracts need to meet specific state public health requirements and must be accessible for review upon request.

Relevant Terms

managed care, capitation payment, medical assistance, performance targets, verification of coverage, enrollee disenrollment, county-based purchasing plans, Medicaid, healthcare services, administrative activities

Bill text versions

Actions

DateChamberWhereTypeNameCommittee Name
March 31, 2025SenateFloorActionIntroduction and first reading
March 31, 2025SenateFloorActionReferred toHealth and Human Services

Citations

 
[
  {
    "analysis": {
      "added": [
        "Introduces a verification of coverage requirement for medical assistance enrollees.",
        "Details criteria for performance targets and reporting requirements for managed care plans."
      ],
      "removed": [],
      "summary": "This bill establishes a medical assistance capitation payment withhold related to verification of coverage, amending the requirements for managed care contracts under section 256B.69, subdivision 5a.",
      "modified": [
        "Adjusts the percentage of withhold for managed care payments and specifies conditions for returning withheld funds."
      ]
    },
    "citation": "256B.69",
    "subdivision": "subdivision 5a"
  }
]

Sponsors