1.1 A bill for an act
1.2 relating to human services; establishing a county-administered rural medical
1.3 assistance program; establishing payment, coverage, and eligibility requirements
1.4 for the CARMA program; directing the commissioner of human services to seek
1.5 federal waivers; amending Minnesota Statutes 2024, section 256B.69, subdivision
1.6 3a; proposing coding for new law in Minnesota Statutes, chapter 256B.
1.7BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.8 Section 1. Minnesota Statutes 2024, section 256B.69, subdivision 3a, is amended to read:
1.9 Subd. 3a.County authority.(a) The commissioner, when implementing the medical
1.10assistance prepayment program within a county, must include the county board in the process
1.11of development, approval, and issuance of the request for proposals to provide services to
1.12eligible individuals within the proposed county. County boards must be given reasonable
1.13opportunity to make recommendations regarding the development, issuance, review of
1.14responses, and changes needed in the request for proposals. The commissioner must provide
1.15county boards the opportunity to review each proposal based on the identification of
1.16community needs under chapters 142F and 145A and county advocacy activities. If a county
1.17board finds that a proposal does not address certain community needs, the county board and
1.18commissioner shall continue efforts for improving the proposal and network prior to the
1.19approval of the contract. The county board shall make recommendations regarding the
1.20approval of local networks and their operations to ensure adequate availability and access
1.21to covered services. The provider or health plan must respond directly to county advocates
1.22and the state prepaid medical assistance ombudsperson regarding service delivery and must
1.23be accountable to the state regarding contracts with medical assistance funds. The county
1.24board may recommend a maximum number of participating health plans after considering
1Section 1.
REVISOR AGW/EN 25-0420903/24/25
State of Minnesota
This Document can be made available
in alternative formats upon request
HOUSE OF REPRESENTATIVES
H. F. No. 2955
NINETY-FOURTH SESSION
Authored by Backer, Bierman, Nadeau, Fischer and Huot04/01/2025
The bill was read for the first time and referred to the Committee on Health Finance and Policy 2.1the size of the enrolling population; ensuring adequate access and capacity; considering the
2.2client and county administrative complexity; and considering the need to promote the
2.3viability of locally developed health plans. The county board or a single entity representing
2.4a group of county boards and the commissioner shall mutually select health plans for
2.5participation at the time of initial implementation of the prepaid medical assistance program
2.6in that county or group of counties and at the time of contract renewal. The commissioner
2.7shall also seek input for contract requirements from the county or single entity representing
2.8a group of county boards at each contract renewal and incorporate those recommendations
2.9into the contract negotiation process.
2.10 (b) At the option of the county board, the board may develop contract requirements
2.11related to the achievement of local public health goals to meet the health needs of medical
2.12assistance enrollees. These requirements must be reasonably related to the performance of
2.13health plan functions and within the scope of the medical assistance benefit set. If the county
2.14board and the commissioner mutually agree to such requirements, the department shall
2.15include such requirements in all health plan contracts governing the prepaid medical
2.16assistance program in that county at initial implementation of the program in that county
2.17and at the time of contract renewal. The county board may participate in the enforcement
2.18of the contract provisions related to local public health goals.
2.19 (c) For counties in which a prepaid medical assistance program has not been established,
2.20the commissioner shall not implement that program if a county board submits an acceptable
2.21and timely preliminary and final proposal under section 256B.692, until county-based
2.22purchasing is no longer operational in that county. For counties in which a prepaid medical
2.23assistance program is in existence on or after September 1, 1997, the commissioner must
2.24terminate contracts with health plans according to section 256B.692, subdivision 5, if the
2.25county board submits and the commissioner accepts a preliminary and final proposal
2.26according to that subdivision. The commissioner is not required to terminate contracts that
2.27begin on or after September 1, 1997, according to section 256B.692 until two years have
2.28elapsed from the date of initial enrollment. This paragraph expires upon the effective date
2.29of paragraph (d).
2.30 (d) Effective January 1, 2027, for counties in which a prepaid medical assistance program
2.31is in existence on or after September 1, 1997, the commissioner must terminate contracts
2.32with health plans according to section 256B.692, subdivision 5, if the county board submits
2.33and the commissioner accepts a preliminary and final proposal according to that subdivision.
2.34 (d) (e) In the event that a county board or a single entity representing a group of county
2.35boards and the commissioner cannot reach agreement regarding: (i) the selection of
2Section 1.
REVISOR AGW/EN 25-0420903/24/25 3.1participating health plans in that county; (ii) contract requirements; or (iii) implementation
3.2and enforcement of county requirements including provisions regarding local public health
3.3goals, the commissioner shall resolve all disputes after taking into account the
3.4recommendations of a three-person mediation panel. The panel shall be composed of one
3.5designee of the president of the association of Minnesota counties, one designee of the
3.6commissioner of human services, and one person selected jointly by the designee of the
3.7commissioner of human services and the designee of the Association of Minnesota Counties.
3.8Within a reasonable period of time before the hearing, the panelists must be provided all
3.9documents and information relevant to the mediation. The parties to the mediation must be
3.10given 30 days' notice of a hearing before the mediation panel.
3.11 (e) (f) If a county which elects to implement county-based purchasing ceases to implement
3.12county-based purchasing, it is prohibited from assuming the responsibility of county-based
3.13purchasing for a period of five years from the date it discontinues purchasing.
3.14 (f) (g) The commissioner shall not require that contractual disputes between county-based
3.15purchasing entities and the commissioner be mediated by a panel that includes a
3.16representative of the Minnesota Council of Health Plans.
3.17 (g) (h) At the request of a county-purchasing entity, the commissioner shall adopt a
3.18contract reprocurement or renewal schedule under which all counties included in the entity's
3.19service area are reprocured or renewed at the same time.
3.20 (h) (i) The commissioner shall provide a written report under section 3.195 to the chairs
3.21of the legislative committees having jurisdiction over human services in the senate and the
3.22house of representatives describing in detail the activities undertaken by the commissioner
3.23to ensure full compliance with this section. The report must also provide an explanation for
3.24any decisions of the commissioner not to accept the recommendations of a county or group
3.25of counties required to be consulted under this section. The report must be provided at least
3.2630 days prior to the effective date of a new or renewed prepaid or managed care contract
3.27in a county.
3.28 EFFECTIVE DATE.This section is effective January 1, 2027.
3.29 Sec. 2. [256B.695] COUNTY-ADMINISTERED RURAL MEDICAL ASSISTANCE
3.30PROGRAM.
3.31 Subdivision 1.Definitions.(a) For the purposes of this section, the following terms have
3.32the meanings given.
3Sec. 2.
REVISOR AGW/EN 25-0420903/24/25 4.1 (b) "CARMA" means the county-administered rural medical assistance program
4.2established under this section.
4.3 (c) "Commissioner" means the commissioner of human services.
4.4 (d) "Eligible individual" means an individual who is:
4.5 (1) residing in a county administering CARMA; and
4.6 (2) eligible for medical assistance, MinnesotaCare, Minnesota Senior Health Options
4.7(MSHO), Minnesota Senior Care Plus (MSC+), or Special Needs Basic Care (SNBC).
4.8 (e) "Enrollee" means an individual enrolled in CARMA.
4.9 (f) "PMAP" means the prepaid medical assistance program under section 256B.69.
4.10 (g) "Rural county" has the meaning given to "rural area" in Code of Federal Regulations,
4.11title 42, section 438.52.
4.12 Subd. 2.Program established.A county-administered rural medical assistance program
4.13is established to:
4.14 (1) provide a county-owned and county-administered alternative to PMAP;
4.15 (2) facilitate integration of health care, public health, and social services to address
4.16health-related social needs in rural communities;
4.17 (3) account for the fewer enrollees and local providers of health care and community
4.18services in rural communities; and
4.19 (4) promote accountability for health outcomes, health equity, customer service,
4.20community outreach, and cost of care.
4.21 Subd. 3.County participation.Each county or group of counties authorized under
4.22section 256B.692 may administer CARMA for any or all eligible individuals as an alternative
4.23to PMAP, MinnesotaCare, MSHO, MSC+, or SNBC programs. Counties choosing and
4.24authorized to administer CARMA are exempt from the procurement process as required
4.25under section 256B.69.
4.26 Subd. 4.Oversight and regulation.CARMA is governed by sections 256B.69 and
4.27256B.692, unless otherwise provided for under this section. The commissioner must develop
4.28and implement a procurement process requiring applications from county-based purchasing
4.29plans interested in offering CARMA. The procurement process must require county-based
4.30purchasing plans to demonstrate compliance with federal and state regulatory requirements
4Sec. 2.
REVISOR AGW/EN 25-0420903/24/25 5.1and the ability to meet the goals of the program set forth in subdivision 2. The commissioner
5.2must review and approve or disapprove applications.
5.3 Subd. 5.CARMA enrollment.(a) Subject to paragraphs (d) and (e), eligible individuals
5.4must be automatically enrolled in CARMA, but may decline enrollment. Eligible individuals
5.5may enroll in fee-for-service medical assistance. Eligible individuals may change their
5.6CARMA elections on an annual basis.
5.7 (b) Eligible individuals must be able to enroll in CARMA through the selection process
5.8in accordance with the election period established in section 256B.69, subdivision 4,
5.9paragraph (e).
5.10 (c) Enrollees who were not previously enrolled in the medical assistance program or
5.11MinnesotaCare can change their selection once within the first year after enrollment in
5.12CARMA. Enrollees who were not previously in CARMA have 90 days to make a change
5.13and changes are allowed for additional special circumstances.
5.14 (d) The commissioner may offer a second health plan other than, and in addition to,
5.15CARMA to eligible individuals when another health plan is required by federal law or rule.
5.16The commissioner may offer a replacement plan to eligible individuals, as determined by
5.17the commissioner, when counties administering CARMA have their contract terminated
5.18for cause.
5.19 (e) The commissioner may, on a county-by-county basis, offer a health plan other than,
5.20and in addition to, CARMA to individuals who are eligible for both Medicare and medical
5.21assistance due to age or disability if the commissioner deems it necessary for enrollees to
5.22have another choice of health plan. Factors the commissioner must consider when
5.23determining if the other health plan is necessary include the number of available Medicare
5.24Advantage Plan options that are not special needs plans in the county, the size of the enrolling
5.25population, the additional administrative burden placed on providers and counties by multiple
5.26health plan options in a county, the need to ensure the viability and success of the CARMA
5.27program, and the impact to the medical assistance program.
5.28 (f) In counties where the commissioner is required by federal law or elects to offer a
5.29second health plan other than CARMA pursuant to paragraphs (d) and (e), eligible enrollees
5.30who do not select a health plan at the time of enrollment must automatically be enrolled in
5.31CARMA.
5.32 (g) This subdivision supersedes section 256B.694.
5Sec. 2.
REVISOR AGW/EN 25-0420903/24/25 6.1 Subd. 6.Benefits and services.(a) County entities administering CARMA must cover
6.2all benefits and services required to be covered by medical assistance under section
6.3256B.0625.
6.4 (b) County entities administering CARMA may include health-related social needs
6.5(HRSN) benefits as covered services under medical assistance as of January 1, 2030.
6.6Coverage for HRSN must be based on the assessed needs of housing, food, transportation,
6.7utilities, and interpersonal safety.
6.8 (c) County entities administering CARMA may reimburse enrollees directly for
6.9out-of-pocket costs incurred obtaining assessed HRSN services provided by nontraditional
6.10providers who are unable to accept payment via traditional health insurance methods.
6.11Enrollees must not be reimbursed for out-of-pocket costs paid to providers eligible to enroll.
6.12 Subd. 7.Payment.(a) The commissioner, in consultation with counties administering
6.13CARMA, must develop a mechanism for the payment of county entities administering
6.14CARMA. The payment mechanism must:
6.15 (1) be governed by contracts with terms, including but not limited to payment rates,
6.16amended on an as-needed basis;
6.17 (2) pay a full-risk monthly capitation payment for services included in CARMA, including
6.18the cost for administering CARMA benefits and services;
6.19 (3) include risk corridors based on minimum loss ratio, total cost of care, or other metrics;
6.20 (4) include a settle-up process tied to the risk corridor arrangement allowing a county
6.21entity administering CARMA to retain savings for reinvestment in health care activities
6.22and operations to protect against significant losses that a county entity administering CARMA
6.23or the state might realize, beginning no sooner than after the county-entity's third year of
6.24CARMA operations;
6.25 (5) include a collaborative rate-setting process accounting for CARMA experience,
6.26regional experience, and the Department of Human Services fee-for-service experience;
6.27and
6.28 (6) be exempt from section 256B.69, subdivisions 5a, paragraphs (c) and (f), and 5d,
6.29and payment for Medicaid services provided under section 256B.69, subdivision 28,
6.30paragraph (b), no sooner than three years after CARMA implementation.
6.31 (b) Payments for benefits and services under subdivision 6, paragraph (a), must not
6.32exceed payments that otherwise would have been paid to health plans under medical
6.33assistance for that county or region. Payments for HRSN benefits under subdivision 6,
6Sec. 2.
REVISOR AGW/EN 25-0420903/24/25 7.1paragraph (b), must be in addition to payments for benefits and services under subdivision
7.26, paragraph (a).
7.3 Subd. 8.Quality measures.(a) The commissioner and county entities administering
7.4CARMA must collaborate to establish quality measures for CARMA not to exceed the
7.5extent of quality measures required under sections 256B.69 and 256B.692. The measures
7.6must include:
7.7 (1) enrollee experience and outcomes;
7.8 (2) population health;
7.9 (3) health equity; and
7.10 (4) the value of health care spending.
7.11 (b) The commissioner and county entities administering CARMA must collaborate to
7.12define a quality improvement model for CARMA. The model must include a focus on
7.13locally specified measures based on the counties' unique needs. The locally specified
7.14measures for the county entity administering CARMA must be determined before the
7.15commissioner enters into any contract with the county entity.
7.16 Subd. 9.Data and systems integration.The commissioner and county entities
7.17administering CARMA must collaborate to:
7.18 (1) identify and address barriers that prevent county entities administering CARMA
7.19from reviewing individual enrollee eligibility information to identify eligibility and to help
7.20enrollees apply for other appropriate programs and resources;
7.21 (2) identify and address barriers preventing county entities administering CARMA from
7.22more readily communicating with and educating potential and current enrollees regarding
7.23other program opportunities, including helping enrollees apply for those programs and
7.24navigate transitions between programs;
7.25 (3) develop and test, in counties participating in CARMA, a universal public assistance
7.26application form to reduce the administrative barriers associated with applying for and
7.27participating in various public programs;
7.28 (4) identify and address regulatory and system barriers that may prohibit county entities
7.29administering CARMA, agencies, and other partners from working together to identify and
7.30address an individual's needs;
7.31 (5) facilitate greater interoperability between county entities administering CARMA,
7.32agencies, and other partners to send and receive the data necessary to support CARMA,
7Sec. 2.
REVISOR AGW/EN 25-0420903/24/25 8.1counties, and local health system efforts to improve the health and welfare of prospective
8.2and enrolled populations;
8.3 (6) support efforts of county entities administering CARMA to incorporate the necessary
8.4automation and interoperability to eliminate manual processes when related to the data
8.5exchanged; and
8.6 (7) support the creation and maintenance by county entities administering CARMA of
8.7an updated electronic inventory of community resources available to assist the enrollee in
8.8the enrollee's HRSN, including an electronic closed-loop referral system.
8.9 EFFECTIVE DATE.This section is effective January 1, 2027.
8.10 Sec. 3. REQUEST FOR FEDERAL WAIVER.
8.11 The commissioner of human services must seek all federal waivers and authority
8.12necessary to implement CARMA. Any part of the CARMA program that does not require
8.13federal approval shall have an effective date as specified in state law. The commissioner of
8.14human services shall notify the revisor of statutes when federal approval is obtained.
8.15 EFFECTIVE DATE.This section is effective the day following final enactment.
8Sec. 3.
REVISOR AGW/EN 25-0420903/24/25