Subdivision 1. Definitions. (a) For the purposes of this section, the following terms have the meanings given them.
(b) "Access" means the availability and timely use of services to achieve optimal outcomes as required under Code of Federal Regulations, part 42, sections 438.68 and 438.206.
(c) "External quality review" means the analysis and evaluation by an external quality review organization of the aggregated information on quality, timeliness, and access to the health care services that a managed care organization or the managed care organization's contractor provides to enrollees.
(d) "External quality review organization" means an organization that meets the competence and independence requirements under Code of Federal Regulations, part 42, section 438.354, and performs external quality review and may perform other external quality review-related activities as required under Code of Federal Regulations, part 42, section 438.358.
(e) "Quality" means the degree that a managed care organization increases the likelihood of desired outcomes of a managed care organization's enrollees through:
(1) a managed care organization's structural and operational characteristics;
(2) the provision of services that are consistent with current professional, evidence-based knowledge; and
(3) interventions for performance improvement.
(f) "Validation" means the review of information, data, and procedures to determine the extent that information, data, and procedures are accurate, reliable, free from bias, and according to standards for data collection and analysis.
Subd. 2. Quality strategy. (a) The commissioner shall implement a written quality strategy for assessing and improving the quality of health care and other services provided by managed care organizations. At a minimum, the quality strategy must include:
(1) defined network adequacy requirements and availability of services standards for managed care organizations, including examples of evidence-based clinical practice guidelines;
(2) measurable goals and objectives for continuous quality improvement that consider the health status of all populations served by the managed care organization;
(3) a description of:
(i) the quality metrics and performance targets used in measuring the performance and improvement of each managed care organization; and
(ii) performance improvement projects, including a description of any intervention proposed by the commissioner to improve access, quality, or timeliness of care for enrollees;
(4) annual, external independent reviews of quality outcomes, and the timeliness of and access to services covered by the managed care organization;
(5) a description of the managed care organization's transition of care policy;
(6) a plan to identify, evaluate, and reduce health disparities based on an enrollee's age, race, ethnicity, sex, primary language, or disability status, and provide this demographic information to the managed care organization at the time of enrollment;
(7) appropriate use of intermediate sanctions to be imposed on a managed care organization;
(8) the mechanisms implemented to identify enrollees who need long-term services and supports or enrollees with special health care needs; and
(9) information related to nonduplication of the external quality review activities in accordance with Code of Federal Regulations, part 42, section 438.360, paragraph (c).
(b) In developing the initial quality strategy, the commissioner shall:
(1) obtain input from the Medicaid Citizens' Advisory Committee, enrollees, and other interested stakeholders;
(2) consult with the tribes according to the tribal consultation policy;
(3) consider recommendations from the external quality review organization identified under subdivision 3, for improving the quality of health care services furnished by the managed care organization; and
(4) make the strategy available for public comment.
(c) The commissioner shall submit a copy of the initial quality strategy to the Centers for Medicare and Medicaid Services for comments and feedback. If significant changes are made based on the comments and feedback received, the commissioner shall publish the revised quality strategy on the department's website. The commissioner shall make the final quality strategy available on the department's website.
(d) The commissioner shall review and update the quality strategy at least every three years or more frequently, if needed. The review shall include an evaluation of the effectiveness of the quality strategy conducted within the previous three years. The results of the review and any updates shall be published on the department's website.
Subd. 3. External quality reviews. (a) The commissioner shall contract with an external quality review organization in accordance with Code of Federal Regulations, part 42, section 438.354, to conduct an annual external quality review of each managed care organization. The commissioner shall ensure that all necessary information is provided to the external quality review organization for analysis and inclusion in the external quality review technical report required under paragraph (g). The information provided must be obtained in accordance with Code of Federal Regulations, part 42, section 438.352.
(b) The commissioner shall follow an open, competitive procurement process according to state and federal law for any contract with an external quality review organization. The external quality review organization may use a subcontractor if the subcontractor meets the requirements for independence. The external quality review organization is accountable for and must oversee all functions performed by the subcontractor.
(c) The following mandatory external quality review related activities must be performed for each managed care organization:
(1) validation of performance improvement projects, performance measures, and meeting network adequacy requirements for the 12 months preceding the most recently completed contract period; and
(2) review of the managed care organization's compliance with Code of Federal Regulations, part 42, subpart D, and section 438.330 for the preceding three years.
(d) The commissioner may elect to incorporate any of the optional activities listed in Code of Federal Regulations, part 42, section 438.358, paragraph (c), as part of the external quality review.
(e) To avoid duplication, the commissioner may use information from a Medicare or private accreditation review to provide information for a managed care organization's annual external quality review instead of conducting one or more of the mandatory external quality review activities. The information used must satisfy Code of Federal Regulations, part 42, section 438.360, paragraph (a).
(f) If the conditions in Code of Federal Regulations, part 42, section 438.362, are satisfied, the commissioner may accept the data, correspondence, information, and findings regarding the managed care organization's compliance with a Medicare quality review in lieu of performing an external quality review. For each managed care organization exempt from an external quality review, the commissioner shall obtain the most recent Medicare review findings or Medicare information from a private national accrediting organization that the Centers for Medicare and Medicaid Services approves and recognizes for Medicare Advantage Organization deeming.
(g) The qualified external quality review organization must produce an annual external quality review technical report in accordance with Code of Federal Regulations, part 42, section 438.364. The technical report must summarize findings on access and quality of care. The commissioner may revise the final external quality review technical report if there is evidence of error or omission. The final external quality review technical report must be published on the department's website by April 30 of each year and copies of the report must be made available upon request and in alternative formats. Information in the technical report must not disclose the identity or other protected patient identifying health information.
1Sp2017 c 6 art 15 s 6
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.