Managed Care Systems

Regulating Health Maintenance Organizations, Provider Network Adequacy, and Consumer Services

The Managed Care Systems Section three primary functions:

1. Regulatory oversight on all Health Maintenance Organizations (HMOs) and County-Based Purchasers (CBPs). Regulatory activities include:
   • Licensing HMOs in Minnesota.
   • Ensuring HMOs and CBPs are following state and federal laws.
   • Ensuring HMOs and CBPs are providing quality care and are financially stable.
   • Reviewing individual and small employer health plans to make sure they meet requirements under the Affordable Care Act.
2. Provider Network Adequacy: This area focuses networks of health care providers that HMOs and health insurance companies have contracts with. Network Adequacy activities include:
   • Reviewing health care provider networks for individual and small employer health insurance plans to determine if they meet statutory requirements.
   • Designating Essential Community Providers.
   • Engaging stakeholders in modernizing and prioritizing network adequacy activities.
3. Consumer Services: This area provides information on health insurance resources, and helps consumers resolve complaints, which includes:
   • Helping consumers with HMO complaints.
   • Helping consumers file external appeals from HMOs.
   • Helping with No Surprises Act (balance billing) complaints.
   • Providing information and consumer education on health insurance and resources for finding care through the Health Information Clearinghouse.

Updates:

• NEW! Details on UCare Minnesota in Receivership
• NEW! FAQs: Preventive Care Coverage and Cost Sharing
• NEW! File an appeal or complaint online using the Managed Care Systems Portal
• FAQs: Prescription Drug Cost Sharing for Certain Chronic Diseases.