Subdivision 1. Definitions. (a) For purposes of this section, the following terms have the meanings given them.
(b) "Adverse benefit determination" has the meaning provided in Code of Federal Regulations, title 42, section 438.400, subpart (b).
(c) "Appeal" means an oral or written request from an enrollee to the managed care organization for review of an adverse benefit determination.
(d) "Commissioner" means the commissioner of human services.
(e) "Complaint" means an enrollee's informal expression of dissatisfaction about any matter relating to the enrollee's prepaid health plan other than an adverse benefit determination.
(f) "Data analyst" means the person employed by the ombudsperson that uses research methodologies to conduct research on data collected from prepaid health plans, including but not limited to scientific theory; hypothesis testing; survey research techniques; data collection; data manipulation; and statistical analysis interpretation, including multiple regression techniques.
(g) "Enrollee" means a person enrolled in a prepaid health plan under section 256B.69. When applicable, an enrollee includes an enrollee's authorized representative.
(h) "External review" means the process described under Code of Federal Regulations, title 42, section 438.408, subpart (f); and section 62Q.73, subdivision 2.
(i) "Grievance" means an enrollee's expression of dissatisfaction about any matter relating to the enrollee's prepaid health plan other than an adverse benefit determination that follows the procedures outlined in Code of Federal Regulations, title 42, part 438, subpart (f). A grievance may include but is not limited to concerns relating to quality of care, services provided, or failure to respect an enrollee's rights under a prepaid health plan.
(j) "Managed care advocate" means a county or Tribal employee who works with managed care enrollees when the enrollee has service, billing, or access problems with the enrollee's prepaid health plan.
(k) "Prepaid health plan" means a plan under contract with the commissioner according to section 256B.69.
(l) "State fair hearing" means the appeals process mandated under section 256.045, subdivision 3a.
Subd. 2. Ombudsperson. The commissioner must designate an ombudsperson to advocate for enrollees. At the time of enrollment in a prepaid health plan, the local agency must inform enrollees about the ombudsperson.
Subd. 3. Duties and cost. (a) The ombudsperson must work to ensure enrollees receive covered services as described in the enrollee's prepaid health plan by:
(1) providing assistance and education to enrollees, when requested, regarding covered health care benefits or services; billing and access; or the grievance, appeal, or state fair hearing processes;
(2) with the enrollee's permission and within the ombudsperson's discretion, using an informal review process to assist an enrollee with a resolution involving the enrollee's prepaid health plan's benefits;
(3) assisting enrollees, when requested, with prepaid health plan grievances, appeals, or the state fair hearing process;
(4) overseeing, reviewing, and approving documents used by enrollees relating to prepaid health plans' grievances, appeals, and state fair hearings;
(5) reviewing all state fair hearings and requests by enrollees for external review; overseeing entities under contract to provide external reviews, processes, and payments for services; and utilizing aggregated results of external reviews to recommend health care benefits policy changes; and
(6) providing trainings to managed care advocates.
(b) The ombudsperson must not charge an enrollee for the ombudsperson's services.
Subd. 4. Powers. In exercising the ombudsperson's authority under this section, the ombudsperson may:
(1) gather information and evaluate any practice, policy, procedure, or action by a prepaid health plan, state human services agency, county, or Tribe; and
(2) prescribe the methods by which complaints are to be made, received, and acted upon. The ombudsperson's authority under this clause includes but is not limited to:
(i) determining the scope and manner of a complaint;
(ii) holding a prepaid health plan accountable to address a complaint in a timely manner as outlined in state and federal laws;
(iii) requiring a prepaid health plan to respond in a timely manner to a request for data, case details, and other information as needed to help resolve a complaint or to improve a prepaid health plan's policy; and
(iv) making recommendations for policy, administrative, or legislative changes regarding prepaid health plans to the proper partners.
Subd. 5. Data. (a) The data analyst must review and analyze prepaid health plan data on denial, termination, and reduction notices (DTRs), grievances, appeals, and state fair hearings by:
(1) analyzing, reviewing, and reporting on DTRs; grievances; appeals; and state fair hearings data collected from each prepaid health plan;
(2) collaborating with the commissioner's partners and the Department of Health for the Triennial Compliance Assessment under Code of Federal Regulations, title 42, section 438.358, subpart (b);
(3) reviewing state fair hearing decisions for policy or coverage issues that may affect enrollees; and
(4) providing data required under Code of Federal Regulations, title 42, section 438.66 (2016), to the Centers for Medicare and Medicaid Services.
(b) The data analyst must share the data analyst's data observations and trends under this subdivision with the ombudsperson, prepaid health plans, and commissioner's partners.
Subd. 6. Collaboration and independence. (a) The ombudsperson must work in collaboration with the commissioner and the commissioner's partners when the ombudsperson's collaboration does not otherwise interfere with the ombudsperson's duties under this section.
(b) The ombudsperson may act independently of the commissioner when:
(1) providing information or testimony to the legislature; and
(2) contacting and making reports to federal and state officials.
Subd. 7. Civil actions. The ombudsperson is not civilly liable for actions taken under this section if the action was taken in good faith, was within the scope of the ombudsperson's authority, and did not constitute willful or reckless misconduct.
2022 c 98 art 2 s 12
Structure Minnesota Statutes
Chapters 245 - 267 — Public Welfare And Related Activities
Chapter 256B — Medical Assistance For Needy Persons
Section 256B.011 — Policy For Childbirth And Abortion Funding.
Section 256B.02 — Definitions.
Section 256B.021 — Medical Assistance Reform Waiver.
Section 256B.03 — Payments To Vendors.
Section 256B.035 — Managed Care.
Section 256B.037 — Prospective Payment Of Dental Services.
Section 256B.0371 — Performance Benchmarks For Dental Access; Contingent Dental Administrator.
Section 256B.038 — Provider Rate Increases After June 30, 1999.
Section 256B.04 — Duties Of State Agency.
Section 256B.041 — Centralized Disbursement Of Medical Assistance Payments.
Section 256B.042 — Third-party Liability.
Section 256B.043 — Cost-containment Efforts.
Section 256B.05 — Administration By County Agencies.
Section 256B.051 — Housing Stabilization Services.
Section 256B.055 — Eligibility Categories.
Section 256B.056 — Eligibility Requirements For Medical Assistance.
Section 256B.0561 — Periodic Data Matching To Evaluate Continued Eligibility.
Section 256B.057 — Eligibility Requirements For Special Categories.
Section 256B.0571 — Long-term Care Partnership Program.
Section 256B.0575 — Availability Of Income For Institutionalized Persons.
Section 256B.058 — Treatment Of Income Of Institutionalized Spouse.
Section 256B.059 — Treatment Of Assets When A Spouse Is Institutionalized.
Section 256B.0594 — Payment Of Benefits From An Annuity.
Section 256B.0595 — Prohibitions On Transfer; Exceptions.
Section 256B.06 — Eligibility; Migrant Workers; Citizenship.
Section 256B.061 — Eligibility; Retroactive Effect; Restrictions.
Section 256B.0615 — Mental Health Certified Peer Specialist.
Section 256B.0616 — Mental Health Certified Family Peer Specialist.
Section 256B.0621 — Covered Services: Targeted Case Management Services.
Section 256B.0622 — Assertive Community Treatment And Intensive Residential Treatment Services.
Section 256B.0623 — Adult Rehabilitative Mental Health Services Covered.
Section 256B.0624 — Crisis Response Services Covered.
Section 256B.0625 — Covered Services.
Section 256B.0626 — Estimation Of 50th Percentile Of Prevailing Charges.
Section 256B.063 — Cost Sharing.
Section 256B.0631 — Medical Assistance Co-payments.
Section 256B.0635 — Continued Eligibility In Special Circumstances.
Section 256B.0636 — Controlled Substance Prescriptions; Abuse Prevention.
Section 256B.0637 — Presumptive Eligibility; Treatment For Breast Or Cervical Cancer.
Section 256B.0638 — Opioid Prescribing Improvement Program.
Section 256B.064 — Sanctions; Monetary Recovery.
Section 256B.0641 — Recovery Of Overpayments.
Section 256B.0642 — Federal Financial Participation.
Section 256B.0643 — Vendor Request For Contested Case Proceeding.
Section 256B.0644 — Reimbursement Under Other State Health Care Programs.
Section 256B.0646 — Minnesota Restricted Recipient Program; Personal Care Assistance Services.
Section 256B.065 — Social Security Amendments.
Section 256B.0651 — Home Care Services.
Section 256B.0652 — Authorization And Review Of Home Care Services.
Section 256B.0653 — Home Health Agency Services.
Section 256B.0654 — Home Care Nursing.
Section 256B.0658 — Housing Access Grants.
Section 256B.0659 — Personal Care Assistance Program.
Section 256B.0671 — Covered Mental Health Services.
Section 256B.0711 — Quality Self-directed Services Workforce.
Section 256B.072 — Performance Reporting And Quality Improvement System.
Section 256B.073 — Electronic Visit Verification.
Section 256B.075 — Disease Management Programs.
Section 256B.0751 — Health Care Homes.
Section 256B.0753 — Payment Restructuring; Care Coordination Payments.
Section 256B.0754 — Payment Reform.
Section 256B.0755 — Integrated Health Partnership Demonstration Project.
Section 256B.0756 — Hennepin And Ramsey Counties Pilot Program.
Section 256B.0757 — Coordinated Care Through A Health Home.
Section 256B.0758 — Health Care Delivery Pilot Program.
Section 256B.0759 — Substance Use Disorder Demonstration Project.
Section 256B.076 — Case Management Services.
Section 256B.08 — Application.
Section 256B.09 — Investigations.
Section 256B.0911 — Long-term Care Consultation Services.
Section 256B.0913 — Alternative Care Program.
Section 256B.0914 — Conflicts Of Interest Related To Medicaid Expenditures.
Section 256B.0916 — Expansion Of Home And Community-based Services.
Section 256B.0917 — Home And Community-based Services For Older Adults.
Section 256B.0918 — Employee Scholarship Costs.
Section 256B.0919 — Adult Foster Care And Family Adult Day Care.
Section 256B.092 — Services For Persons With Developmental Disabilities.
Section 256B.0921 — Home And Community-based Services Innovation Pool.
Section 256B.0922 — Essential Community Supports.
Section 256B.0924 — Targeted Case Management Services.
Section 256B.0926 — Admission Review Team; Intermediate Care Facilities.
Section 256B.093 — Services For Persons With Traumatic Brain Injuries.
Section 256B.094 — Child Welfare Targeted Case Management Services.
Section 256B.0943 — Children's Therapeutic Services And Supports.
Section 256B.0945 — Services For Children With Severe Emotional Disturbance.
Section 256B.0946 — Children's Intensive Behavioral Health Services.
Section 256B.0947 — Intensive Rehabilitative Mental Health Services.
Section 256B.0948 — Foster Care Rate Limits.
Section 256B.0949 — Early Intensive Developmental And Behavioral Intervention Benefit.
Section 256B.095 — Quality Assurance System Established.
Section 256B.0951 — Quality Assurance Commission.
Section 256B.0952 — County Duties; Quality Assurance Teams.
Section 256B.0953 — Quality Assurance Process.
Section 256B.0954 — Certain Persons Defined As Mandated Reporters.
Section 256B.0955 — Duties Of The Commissioner Of Human Services.
Section 256B.097 — Regional And Systems Improvement For Minnesotans Who Have Disabilities.
Section 256B.12 — Legal Representation.
Section 256B.121 — Treble Damages.
Section 256B.14 — Relative's Responsibility.
Section 256B.15 — Claims Against Estates.
Section 256B.17 — Transfers Of Property.
Section 256B.18 — Methods Of Administration.
Section 256B.19 — Division Of Cost.
Section 256B.194 — Federal Payments.
Section 256B.196 — Intergovernmental Transfers; Hospital And Physician Payments.
Section 256B.197 — Intergovernmental Transfers; Inpatient Hospital Payments.
Section 256B.1973 — Directed Payment Arrangements.
Section 256B.198 — Payments For Non-hospital-based Governmental Health Centers.
Section 256B.199 — Payments Reported By Governmental Entities.
Section 256B.20 — County Appropriations.
Section 256B.21 — Change Of Residence.
Section 256B.22 — Compliance With Social Security Act.
Section 256B.23 — Use Of Federal Funds.
Section 256B.24 — Prohibitions.
Section 256B.25 — Payments To Certified Facilities.
Section 256B.26 — Agreements With Other State Departments.
Section 256B.27 — Medical Assistance; Cost Reports.
Section 256B.30 — Health Care Facility Report.
Section 256B.32 — Facility Fee Payment.
Section 256B.35 — Personal Needs Allowance; Persons In Certain Facilities.
Section 256B.36 — Special Personal Allowance For Certain Individuals.
Section 256B.37 — Private Insurance Policies, Causes Of Action.
Section 256B.39 — Avoidance Of Duplicate Payments.
Section 256B.40 — Subsidy For Abortions Prohibited.
Section 256B.421 — Definitions.
Section 256B.431 — Rate Determination.
Section 256B.434 — Payment Rates And Procedures; Contracts And Agreements.
Section 256B.439 — Long-term Care Quality Profiles.
Section 256B.48 — Conditions For Participation.
Section 256B.49 — Home And Community-based Service Waivers For Persons With Disabilities.
Section 256B.4905 — Home And Community-based Services Policy Statement.
Section 256B.4911 — Consumer-directed Community Supports.
Section 256B.4912 — Home And Community-based Waivers; Providers And Payment.
Section 256B.4914 — Home And Community-based Services Waivers; Rate Setting.
Section 256B.492 — Home And Community-based Settings For People With Disabilities.
Section 256B.493 — Adult Foster Care Planned Closure.
Section 256B.501 — Rates For Community-based Services For Persons With Disabilities.
Section 256B.5011 — Icf/dd Reimbursement System Effective October 1, 2000.
Section 256B.5012 — Icf/dd Payment System Implementation.
Section 256B.5013 — Payment Rate Adjustments.
Section 256B.5014 — Reporting Requirements.
Section 256B.5015 — Pass-through Of Other Services Costs.
Section 256B.51 — Nursing Homes; Cost Of Home Care.
Section 256B.69 — Prepaid Health Plans.
Section 256B.6903 — Ombudsperson For Managed Care.
Section 256B.691 — Risk-based Transportation Payments.
Section 256B.692 — County-based Purchasing.
Section 256B.6925 — Enrollee Information.
Section 256B.6926 — State Monitoring.
Section 256B.6927 — Quality Assessment And Performance.
Section 256B.6928 — Managed Care Rates And Payments.
Section 256B.693 — State-operated Services; Managed Care.
Section 256B.694 — Sole-source Or Single-plan Managed Care Contract.
Section 256B.70 — Demonstration Project Waiver.
Section 256B.71 — Social Health Maintenance Organization Demonstration.
Section 256B.72 — Commissioner's Recovery Of Overpayments.
Section 256B.73 — Demonstration Project For Uninsured Low-income Persons.
Section 256B.74 — Special Payments.
Section 256B.75 — Hospital Outpatient Reimbursement.
Section 256B.756 — Reimbursement Rates For Births.
Section 256B.758 — Reimbursement For Doula Services.
Section 256B.76 — Physician And Dental Reimbursement.
Section 256B.761 — Reimbursement For Mental Health Services.
Section 256B.762 — Reimbursement For Health Care Services.
Section 256B.763 — Critical Access Mental Health Rate Increase.
Section 256B.7635 — Reimbursement For Evidence-based Public Health Nurse Home Visits.
Section 256B.764 — Reimbursement For Family Planning Services.
Section 256B.765 — Provider Rate Increases.
Section 256B.766 — Reimbursement For Basic Care Services.
Section 256B.767 — Medicare Payment Limit.
Section 256B.77 — Coordinated Service Delivery System For Persons With Disabilities.
Section 256B.771 — Complementary And Alternative Medicine Demonstration Project.
Section 256B.78 — Demonstration Project For Family Planning Services.
Section 256B.79 — Integrated Care For High-risk Pregnant Women.
Section 256B.795 — Maternal And Infant Health Report.
Section 256B.81 — Mental Health Provider Appeal Process.
Section 256B.82 — Prepaid Plans And Mental Health Rehabilitative Services.
Section 256B.84 — American Indian Contracting Provisions.
Section 256B.85 — Community First Services And Supports.
Section 256B.851 — Community First Services And Supports; Payment Rates.