SF3190 (Legislative Session 94 (2025-2026))
Medical capitation payment withhold related to verification of coverage establishment
AI Generated Summary
Purpose of the Bill
The bill aims to establish a system for withholding a portion of payments made to managed care and county-based purchasing plans under the medical assistance program, ensuring compliance with coverage verification and performance targets.
Main Provisions
Performance Target Withholding: The bill mandates that the commissioner withholds a specific percentage of payments to managed care plans and county-based purchasing plans until performance targets are met. These targets are quantitative, objective, measurable, and should include efforts to manage health care spending and administrative activities.
Verification of Coverage Requirement: Starting January 1, 2026, two percent of the capitation payment for each medical assistance enrollee will be withheld until the managed care plans submit a verification of coverage form completed and signed by the enrollees.
Return of Withheld Funds: Withheld funds are returned no sooner than July and no later than July 31 the following year if performance targets are achieved, and the verification form is completed correctly.
Conditions for Payment and Enrollment: If an enrollee’s verification form is not submitted by February 28, 2026, funds will not be returned for that enrollee, capitation payments for the enrollee will cease starting April 2026, and the enrollee will be disenrolled from the medical assistance program, subject to appeal.
Significant Changes to Existing Law
- The bill modifies current managed care contracts by implementing a system of withholding payments based on the submission of a verification of coverage form and fulfillment of defined performance targets.
- Changes the process by which plans must demonstrate compliance with contractual obligations, specifically focusing on their ability to properly verify enrollee coverage.
Relevant Terms
managed care, capitation payment, performance targets, verification of coverage, medical assistance, withholding funds, compliance, disenrollment, enrollee appeal.
Bill text versions
- Introduction PDF file
Actions
| Date | Chamber | Where | Type | Name | Committee Name |
|---|---|---|---|---|---|
| March 31, 2025 | Senate | Floor | Action | Introduction and first reading | |
| March 31, 2025 | Senate | Floor | Action | Referred to | Health and Human Services |
Citations
[
{
"analysis": {
"added": [
"A new withhold system contingent upon enrollee verification of coverage forms."
],
"removed": [
"Historical performance withhold percentages and dates specific to services from 2013 and 2014."
],
"summary": "This bill modifies the managed care contracts requirements under section 256B.69, subdivision 5a, related to withholding capitation payments pending performance targets.",
"modified": [
"Updates standards for performance targets and outlines forms required by managed care plans."
]
},
"citation": "256B.69",
"subdivision": "subdivision 5a"
},
{
"analysis": {
"added": [
"References to disenrollment processes tied to performance and verification of coverage."
],
"removed": [],
"summary": "The bill affects terms related to county-based purchasing plans related to the withholding of funds for performance targets.",
"modified": []
},
"citation": "256B.692",
"subdivision": ""
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "Exemption from set-aside and preference provisions in the context of prepaid health plan contracts.",
"modified": [
"Exemptions now apply to managed care plan contracts."
]
},
"citation": "16C.16",
"subdivision": "subdivisions 6 and 7"
},
{
"analysis": {
"added": [
"Managed care plans can include expected withheld returns as assets."
],
"removed": [],
"summary": "This citation allows managed care and purchasing plans to include withheld payments as admissible assets.",
"modified": []
},
"citation": "62D.044",
"subdivision": ""
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "Addresses the handling of nonpublic data in relation to subcontractor documentation access.",
"modified": [
"Clarifies the non-disclosure of nonpublic data in subcontractor agreements."
]
},
"citation": "13.02",
"subdivision": ""
}
]