To: From: Date: Re: MPMA Podiatrists Michelle M. Barrette Thursday, March 8, 2012 Senate Independent Third Party Audits of Health Plans Senate File (S.F.) 1824

Attached is a list of Senate Health and Human Services Committee Members. If your State Representative is on this list the MPMA needs for you to inunediately contact your legislator with the message below. You recently received a legislative alert regarding the HOUSE Health and Human Services Committee meeting. This is a different request! If you do not know who your legislator is please use the following link to find out! It's easy.

Who Represents Me?







2011 - 2012
Telephone Contact by Email

Legislative District



42 24 8 49 14 40 61 58 10 54 18 17 23


Hann, David W. Rosen, Julie A. Loure~, Ton~ Benson, Michelle R. Fischbach, Michelle L. Hall, Dan D. Ha~den, Jeff Higgins, Linda Hoffman, Gretchen M. Mart~, John Newman, Scott J. Nienow, Sean R. Sheran, I(ath~

(651) 296-1749 (651) 296-5713 (651) 296-0293 (651) 296-3219 (651) 296-2084 (651) 296-5975 (651) 296-4261 (651) 296-9246 (651) 296-5655 (651) 296-5645 (651) 296-4131 (651) 296-5419 (651) 296-6153 sen.scott.newman@senate.mn sen.sean.nienow@senate.mn sen.kath~.shera n@senate.mn sen.julie.rosen@senate.mn sen.ton~.loure~@senate.mn sen.michelle.benson@senate.mn sen.michelle.fischbach@senate.mn sen.dan.hall@senate.mn sen. jeff.ha~den @senate.mn sen.linda.higgins@senate.mn sen.gretche n. hoffm an@senate.mn

Please do the following: 1. 2. Contact your legislator using the information in this action request. Ask your legislator to vote for S.F. 1824. State that we need to how over 4 billion dollars of our tax dollars are spent on the health administration of Medicaid funds. Let them know as providers reimbursement has dramatically diminished each and every year health plan reserves increase. know plans your while

The SENATE Health and Human Services Committee 'will likely hear S.F. 1824 on MONDAY, MARCH 12, 2012 at 1:00 p.m. or in the evening, in Room 15 of the State Capitol. Attached is a copy of S.F. 1824. (Independent audits of health plans Medicaid funds.) With your legislator's help we anticipate S.P. 1824 to pass out of this committee which will then likely go to the Senate t100r for passage. 2

The following information can be used to educate yourself on the issue Six page summary on the issues. (Attached).

KSTP TV - Feds Investigate Minnesota HMOs and State Agency Over Billions in Tax Money http://kstp.com/article/stories/S2495459.shtml HMO Black Box web site www.HMOBlackBox.com

3. 4.

Urge your legislators support S.F. 1824. Report to me any legislator reply to your request. or 651-485-7999. MicheUe@sivbar.com

Call me with any questions.

Michelle M. Barrette Attorney ILobbyist MINNESOTA PODIATRIC MEDICAL ASSOCIATION (MPMA) Michelle@sivbar .com MMB:pmc Enclosure


S.F. No. 1824, as introduced

- 87th Legislative Session (2011-2012) [12-5123]



S.F. No. 1824

Introduction and first reading Referred to Health and Human Services


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A bill for an act relating to health; requiring certain changes in managed care plan financial reporting; requiring an annual independent third-party audit; amending Minnesota Statutes 2011 Supplement, section 256B.69, subdivision 9c. BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

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Section 1. Minnesota Statutes 2011 Supplement, section 256B.69, subdivision 9c, is amended to read: Subd. 9c. Managed care financial reporting. (a) The commissioner shall collect

detailed data regarding financials, provider payments, provider rate methodologies, and other data as determined by the commissioner and managed care and county-based purchasing plans that are required to be submitted under this section. The commissioner, in consultation with the commissioners of health and commerce, and in consultation with managed care plans and county-based purchasing plans, shall set uniform criteria, definitions, and standards for the data to be submitted, and shall require managed care and county-based purchasing plans to comply with these criteria, definitions, and standards when submitting data under this section. In carrying out the responsibilities of this subdivision, the commissioner shall ensure that the data collection is implemented in an integrated and coordinated manner that avoids unnecessary duplication of effort. To the extent possible, the commissioner shall use existing data sources and streamline data collection in order to reduce public and private sector administrative costs. Nothing in this subdivision shall allow release of information that is nonpublic data pursuant to section 13.02. (b) Each managed care and county-based purchasing plan must annually provide to the commissioner the following information on state public programs, in the form

Section 1.

S.F. No. 1824, as introduced
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- 87th Legislative Session (2011-2012) [12-5123]

and manner specified by the commissioner, according to guidelines developed by the commissioner in consultation with managed care plans and county-based purchasing plans under contract: (1) administrative expenses by category and subcategory consistent with administrative expense reporting to other state and federal regulatory agencies, by program; (2) revenues by program, including investment income; (3) nonadministrative service payments, provider payments, and reimbursement

rates by provider type or service category, by program, paid by the managed care plan under this section or the county-based purchasing plan under section 256B.692 to providers and vendors for administrative services under contract with the plan, including but not limited to: (i) individual-level provider payment and reimbursement rate data; (ii) provider reimbursement rate methodologies by provider type, by program, including a description of altemative payment arrangements and payments outside the claims process; (iii) data on implementation of legislatively mandated provider rate changes; and (iv) individual-level provider payment and reimbursement rate data and plan-specific provider reimbursement rate methodologies by provider type, by program, including alternative payment arrangements and payments outside the claims process, provided to the commissioner under this subdivision are nonpublic data as defined in section 13.02; (4) data on the amount of reinsurance or transfer of risk by program; and (5) contribution to reserve, by program. (c) In the event a report is published or released based on data provided under this subdivision, the commissioner shall provide the report to managed care plans and county-based purchasing plans 30 days prior to the publication or release of the report. Managed care plans and county-based purchasing plans shall have 30 days to review the report and provide comment to the commissioner. Cd)The commissioner shall require, in the request for bids and the resulting contracts for coverage to be provided under this section, that each managed care and county-based purchasing plan submit to and fully cooperate with an annual independent third-party financial audit of the information required under paragraph Cb). For purposes ofthis paragraph, "independent third party" means that the audit must be conducted by a firm that performs audits only for govemmental entities and does not provide or receive, and has not provided or received. payment for actuarial. aUditing, accounting, or other services provided by the firm. or by any affiliate of the firm. to a managed care

Section 1.


S.F. No. 1824, as introduced
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- 87th Legislative Session (2011-2012) [12-5123]

or county-based purchasing plan, or to any affiliate of either, that is awarded a contract with the commissioner under this section. (e) The commissioner shall not contract, for purposes of this section, with a firm that provides consulting or other services to a participating managed care or county-based purchasing plan, regardless of whether the consulting services are related to health care provided under this section.
(f) A managed care plan or county-based purchasing plan that provides services

under this section shall provide complete real-time encounter and claims data at the granular or source level regarding those services to the commissioner and shall, upon request of the commissioner, promptly provide the commissioner and the independent third-party auditing firm with auditable proof that the encounters and claims are occurring as reported. (g) Contracts awarded under this section to a managed care or county-based purchasing plan must provide that the commissioner and the contracted auditor shall have unlimited access to any and all data required to complete the audit and that this access shall be enforceable in a court of competent jurisdiction through the process of injunctive or other appropriate relief. (h) No actuary or actuarial firm providing actuarial services to the commissioner in connection with this subdivision shall provide services to any managed care or county-based purchasing plan participating in this subdivision during the tenn of the actuary's work for the commissioner under this subdivision.
(i) The actuary or actuarial firm referenced in paragraph (h) shall certify and attest

to the rates paid to managed care plans and county-based purchasing plans under this section, and the certification and attestation must be auditable.
(j) The independent third-party audit shall include a detennination

of compliance

with the federal Medicaid rate certification process. (k) The commissioner's contract with the independent third-party auditing finn shall be designed and administered so as to render the independent third-party audit eligible for a federal subsidy if available for that purpose.
(I) Upon completion of the audit, and its receipt by the commissioner, the

commissioner shall provide copies of the audit report to the legislative auditor, the attorney general, and the chairs of the health finance committees of the legislature. EFFECTIVE DATE. This section is effective the day following final enactment

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and applies to contracts, and the contracting process, for contracts that are effective January 1,2013, and thereafter.

Section 1.


A Summary of the Minnesota Medicaid/HMO Problem

Minnesota began a pilot program in or around 1996 called the Prepaid Medical Assistance Program in which the state outsourced its Medicaid and state funded public health care programs to primarily (99%) four HMOs, Blue Cross Blue Shield, Health Partners, Medica and U-Care. This program was limited to the seven county metro area. Never has there been an independent audit of these programs. This summary will use the Government Accountability Office (GAO) report of August 2010 as the back drop for explaining how the investigation by Dr. David Feinwachs with the assistance of Senator Sean Nienow and others provides demonstrable evidence that the risks and problems cited in the GAO report have occurred and are still occurring in Minnesota, Furthermore, this summary intends to demonstrate a compelling need for Congressional intervention due to inaction on the part of the Centers for Medicare/Medicaid Services and an unwillingness or inability of the current administration in Minnesota State Government to bring a proper remedy to this problem. The GAO Report, MEDICAID MANAGED CARE CMS's Oversight of States' Rate Setting Needs Improvement, issued in August of 2010 found that CMS had been inconsistent in its review of states rate setting process, inconsistent in its tracking of states compliance with requirements to use actuarially sound standards, and inconsistent in its duty to ensure quality data was being used to set rates for Medicaid enrollees. In fact, the report said CMS generally ensured the quality of data by relying on assurances from the states and the HMO's rather than independently verifying the data. CMS focused on the appropriateness of the data rather than the reliability of the data, i In essence, the HMO Plans self audit and self report. Senator Sean Nienow and Senator John Marty can attest to this lack of oversight with CMS because they made numerous requests to CMS with letters, phone calls and conference calls asking for all independent audit. On one such conference call CMS told the senators and several others in attendance that they thought Minnesota WAS doing independent audits. The letters included in this report show that CMS was contacted, was asked to investigate but took no action. When CMS granted the 1115 Waiver (permission to continue to outsource Medicaid) to Minnesota in July of 2011 they included additional reporting requirements but again, took no action to ensure the data used in those reports was accurate." Note that this limited and ineffective action was taken a year after the GAO report had been published and numerous requests from Sens. Nienow and Marty had been made. The GAO Report reiterated the CMS regulations defining actuarially sound rates as those that are (1) developed in aCCOrdaI1Ce with generally accepted actuarial principles and practices; (2) appropriate for the populations to be covered and the services to be furnished; and (3) certified as meeting applicable regulatory requirements by qualified actuaries. iii This requirement is particularly problematic in light of the information Sen. Nienow obtained from the Department of Human Services when he asked them about the actuary with whom they contract. Specifically, the question was asked if the actuary for the state was also allowed to contract with the HMO Plans. In their written response they stated, "DHS has a contract with Milliman for actuarial services related to Minnesota Health Care Programs. The current contract prohibits the actuary from entering into consulting contracts with the health plans that deliver PMAP services. Past

administrations have permitted actuaries that contract with the state to enter into consulting contracts with the health plans that have PMAP contracts." Iv It would be highly improper for the actuary who contracts with the HMO Plans to set the reimbursement rate to also be the actuary who certifies that rate for the state and reports that certification to eMS. Additionally problematic is the letter from the American Academy of Actuaries which admits that no such standards of actuarial soundness exist for use in the rate setting process of Medicaid programs. v This is also confirmed in the GAO Report."
The Minnesota Office of Legislative Auditor wrote in his report from 2008, Financial Management of Health Care Programs, "It is not entirely clear what constitutes an "actuarially sound" rate. There are no "actuarial standards of practice" that govern certification of rates for Medicaid programs.t'" It is remarkable and necessary to note that in all the letters received by the state's actuary, Milliman, there is a disclaimer that, in essence, says they are not required to audit the data, look for misrepresentations or fraud. If the data used to compile the report is erroneous then the certification of the report is also erroneous. This would be particularly troublesome if the actuary for the state is also consulting with the plans to set the rates. viii At this point it is worth noting a few other statements

from the Auditor's





Minnesota law no longer caps the health plans net worth (pg 46) Minnesota's health plans are non-profit but are allowed to keep their surplus revenues from state programs. (pg 41) In recent years Plans have not reported aggregate losses from public programs. (pg 42) However, health plans have consistently reported losses for the General Assistance Medical Care Program. (pg 43) Minnesota's managed care rates for public programs are relatively high compared with other states. (pg 38) Minnesota's managed care spending per enrollee grew faster than the national rate in recent years. (pg 40) The Department of Health relies largely on the Department of Commerce to assess health plans financial activities. (pg 68) The Department of Commerce reviews the "reasonableness" of health plan expenditures only at a broad aggregate level. (pg 69)

There are several reasons why these statements from the legislative auditor require attention. Minnesota law requires a minimum profit margin for the health plans but no cap. On their own website the MN Department of Health reported that the plans made on average -1 to +3% profit on their commercial insurance but they made up to 12% profit on their public health programs. The MN Department of Health's website no longer exists but the profit margin statement is consistent according to a Star Tribune Editorial by Jill Bercum in which she cites a comparison made between Minnesota, Michigan and Wisconsin. The article says,

There ·was also a striking difference in the annual operating margins of the plans 011 lvledicaid managedcare enrollees. In 2010, in Minnesota, the average annual operating margin was 8.9 percent; Michigan's 2010 average was 2.4 percent, and Wisconsin's 2009 average was 2.6 percent. Rick Murdock, the executive director of the Michigan Association of Health Plans, said that margins are necessary to ensure plans' financial vitality. Of Minnesota's 8.9 average operating margin in 2010, he said: "I'm just surprised that anyone would have that high a margin in the lvledicaid area. Quite frankly, [even} in the commercial area, that would be a high margin. "ix


In addition to profit margins, administrative costs are also inconsistent. The MN Council of Health Plans states on their website that admin istrative costs have remained a constant 9-10% for many years. x However the OLA Report says the Plans administrative costs were 5%.xi When the same entities report different numbers to different people, this cries out for an independent audit. Across the nation there have been numerous news reports that insurance companies are getting out of the insurance business and getting into the public program administration business because of the profitability of that market." Given the reports that the plans made little profit on their commercial products one must ask how can it be that the four HMOs increased their total reserves by over a billion dollars in 2011 (according to the Department of Commerce). The state paid out $3.2 billion that year. The Legislative Auditor reported that the Department of Health relied largely on the Department of Commerce to assess the health plans' financial activities. On February 14, 2012 in a joint committee hearing of the Minnesota Health and Human Services Ref 01111 and Health and Human Services Finance Committees discussing HMO Transparency the question came up regarding the disparity among the levels of reserves held by the HMO Plans. The Actuary for the Commerce Department was present to answer the question. However, when pressed for an answer specific to the public health programs risk and reserves and specifically, how much risk existed in programs such as PMAP, she could not answer and deferred to the Commissioner of the Department of Human Services. This inability of the actuary for the Department charged with oversight of the financial activities of the HMOs is seriously disturbing and begs the question, if Commerce does not know what the level of risk is and how much the HMO Plans should be holding in reserves and DHS does not know, who knows, and who is accountable for the oversight of this?Xiii Also, the Department of Commerce admits they only look at overall solvency of the HMOs. They do not do the type of granular/forensic audit that is needed according to the GAO report and that Sen. Nienow is asking for in his legislation SF1824. The results ofthe GAO report coupled with the inability of the Department of Human Services in Minnesota to provide sufficient answers to the questions regarding lack of transparency and accountability in the PMAP program warrant a legislative remedy. Senator Nienow proposed several bills to provide that remedy in the 2011 legislative session, None of those bills received a hearing. Some say it is due to the 27 lobbyists that converged on the capitol to shut down that effort. None the less, Senator Nienow has introduced legislation in SF1824 (2012) that achieves three goals. First, it calls for a truly independent third party audit by an entity that neither contracts with the department nor the HMO Plans. Secondly, it puts into statute a prohibition of the actuary for the state being able to contract with the HMO Plans. This is too egregious a conflict of interest to leave to the changing nature of departmental contracts. Lastly, the bill requires encounter (claims) data and payment data be linked so the state can be sure they are vigilant stewards of the taxpayer dollars. The next part of this summary will focus on the U-Care Refund of $30 million in 2011, the Competitive Bidding Executive Order and the documents obtained from FOrA requests and in the discovery phase of a wrongful termination lawsuit filed by Dr. David Feinwachs against the MN Council of Health Plans, Providing these documents to you may be helpful in your determination of whether what is occurring in Minnesota rises to the nature of potential fraud 3

and warrants immediate intervention at the federal level. We think it does and ask that you view these documents in light of the risks and problems cited in the GAO report. U-Care Letter and Refund In March 2011 U-Care sent a letter to select lawmakers identifying made to the state. The most telling part of the letter is the stated, "Historically, DHS rates setfor General Assistance Medical losses which were offset by higher Medical Assistance payments. managed care in mid-year 2010, Medical Assistance rates were overpayment. »xiv a $30 million refund being second bullet point which Care resulted in health plan When GAlvIC moved out of not lowered to reflect this

Numerous questions arise from this statement. Is this the correct amount for a refund? Why did the other 3 HMO's not refund for the same "overpayment"? Is it lawful and permissible to offset GAMC losses with higher Medical Assistance payments when GAMC is a state-only funded program and Medicaid is federally funded? Did the federal government know this offset was taking place? If this offset by higher Medical Assistance payments is not permissible, and U-Care gave back an overpayment of 6 months time, and this has been going on since 2003, could there be potentially hundreds of millions of dollars owed back to the government by U-Care and the other 3 HMO's? The only way to verity the numbers is with a truly independent audit. The U-Care refund is also the topic of several emails, the most significant of which is the email from Commissioner Lucinda Jesson of the Department of Human Services to Dan Pollick, a high level staffer, dated March 15th, 2011, the day before the U-Care letter was delivered. In this email Jesson says, "In order to have a good chance of keeping all this money, it must be characterized as a donation. 1f a refund, feds clearly get half Can you work 'with Scott 017 redrafting? Also, I thought 'we 'were going to handle this through phone calls. "xv Other emails also discuss the refund and the appropriateness of the state keeping it and the questions it may raise about the PMAP contracts and the adequacy of Plans' reserves. It invokes no confidence in the Governor's administration when, after being asked about this email, the U-Care refund and the rate manipulations, Commissioner Jesson's response to KSTP reporter Jay Kolls was, "We're not doing it that way, anymore."

Competitive Bidding During the 20 11 Legislative Session, Governor Dayton issued an Executive Order calling for an audit by the Department of Commerce and his administration initiated a competitive bidding process to be used in awarding the PMAP contracts.xvi This order was the basis for the bidding process used for the first time in Fall 20 11, and there were various news reports saying the new process had saved the state approximately 200 million dollars. However, when Senator Nienow inquired about the bidding process it was difficult to get sufficient answers about how it worked. It appears that prior to the bidding process there were 5 HMOs with contracts, the four listed earlier in this summary and a small I% player named Metropolitan Heath. After the bidding process the same four HMOs were awarded contracts. Metropolitan Health which had only 1% of the PMAP enrollees lost the bid altogether but the other four won. The DHS reported that the "best value" Plans were U-Care and Health Partners and as such Blue Cross Blue Shield and Medica were the worst valued Plans or the "losers." It is problematic and puzzling that the two "losers" got Hennepin, Ramsey and Dakota Counties, the most populated counties in the metro area and the two "best value" plans got the other 4 counties. Repeated inquiries to DHS as to what the total enrollee count per county per plan went unanswered as of this writing. The state spent $3.2 Billion dollars in 20 II and will spend $4.2 billion in 2012 for these welfare programs. One has to wonder if the 4

new competitive bidding process resulted in nearly the same proportion of business being allotted to the HMO. The new competitive bidding process raises more questions than it provides answers and there is a compelling need to bring in the audits necessary to see exactly what is going on.xvii

Court Documents The court obtained documents included with this summary can be divided into three groups. The first group is the Karen Peed documents. The second group are the Ll-Care Refund emails some of which were cited previously and the rest require a more thorough explanation. The third group of emails are the Internal Chatter emails that reveal a dialogue that existed among the HMO Plans, the MN Council of Health Plans, Karen Peed from the DHS and the topic of those emails is the investigation by Dr. Feinwachs into the lack of transparency in the PMAP program. Karen Peed was the director of the HMO contracts program for decades. She was overheard on a conference call saying what Dr. Feinwachs remembered as, "If you can't keep a secret you have to leave the room but we have been adjusting the reserve amount for state -only funded programs by making it essentially zero, increasing the amount for PMAP federal programs, blending the rate and returning it to the insurers." Karen Peed was asked in deposition about this statement and her response was that she remembered the call but did not recall making those statements. xviii Another person on the conference call by the name of Matt Anderson was also deposed and he recounted the conversation as Dr. Feinwachs remembered ieix Nancy Feldman, CEO of Ucare, was also asked in deposition about the PMAP and GAMC programs and specifically why one cannot look at them separately. Her response was, "Because the way we look at our products us total bottom line, the State products. The products all intertwine. It is vel]! difficult to pull them apart and look at the bottom line. Two weeks after Karen Peed gave her deposition she was removed from her position as the director of the PMAP contracts program and reassigned to another position.?'

The last group of emails included with this summary are the Internal Chatter emails that reveal a dialogue occurred between the Plans, the MN Council of Health Plans and Karen Peed from DHS. These emails are remarkable because they prompt several questions, some of which are, why did Karen Peed take her concerns about questions of transparency to the Plans rather than to her boss, then current commissioner, Cal Ludeman? Why did they say the Plans would never reveal what they pay to providers? Why did they focus on getting the president of the MN Hospital Association to terminate Dr. Feinwachs rather than on full disclosure of the way they manage the PMAP programs? Dr. Feinwachs was terminated from his almost 30 year career with the MN Hospital Association two months after he reported the Karen Peed statement to the association president. Why was there dialogue about collusion and fraud, calling what Feinwachs was doing "really bad" when he was simply saying that the program lacked transparency'Z" Senator Nienow also saw it as a red flag that the Plans responded to his legislation in 2011 in a way that seemed out of proportion for a reasonable effort to bring accountability to the PMAP programs. Senator Nienow continues to describe this issue with the analogy of a house. In 2011 he smelled something and took reasonable measures to find out what it was. Now there is smoke everywhere and he simply needs to make sure the house isn't on fire. His legislation aims to get to the bottom of the transparency issue, put in measures to strengthen the accountability of the program and return or reaffirm the integrity of Public Health Care in Minnesota. This summary recounts the main aspects of this issue but by no means provides a complete explanation of all the documents and factors that make a compelling case for additional investigation. The efforts made at the state legislature may not be adequate to solve this problem due to factors cited here and factors that can be disclosed in greater detail in a more thorough explanation.


The GAO Report concluded in their assessment a need for improvements stating that the Medicaid program was at risk of losing billions of dollars, Now in Minnesota it appears evident this loss is occurring. The bottom line is that we don't know if there are errors or what the potential for fraud is because we have not done an independent third party audit. There is an imperative need for this audit to be done immediately, accurately and by the proper authorities.

i .Report to Congressional Committees, United States Government Accountability Office, MEDICAID MANAGED CARE CMS's Oversight of States' Rate Setting Needs Improvement pg.2
CMS Letters (Attachment) GAO Report pg 6 http://www.gao.gov/products/GAO-l0-810 IV Competitive Bidding Questions for DHS, Ques. # 2 (attachment) v Letter American Academy of Actuaries (attachment) vi GAO Report pg. 8 vii OLA Evaluation Report, Financial Management of Health Care Programs, pg 36 http://www.auditor.leg.state.mn.us/ped/pedrep/healthcare.pdf viii Milliman letters http://www.publicrecordmedia.com/wpcontent/uploads/2010/documents/MNGDPAMNDHS2011 pd 037.jpg IX http://www.startribune.com/opinion/editorials/139483223.html X http://www.mnhealthplans.org/about/health_ care _facts.cfm xi OLA Report page 73 xii Article on Profitability of managed care http://www.nationaljournal.com/healthcare/report-health-insuranceprofits-rise-despite-health-care-reform-20 120 105 xiii Joint House HHS Hearing Feb. 14th http://www.house.leg.state.mn.us/htv/programa.asp?ls _year=87 &event_ id=4023 xiv V-Care Letter (attachment) xv Jessonl Pollock email (attachment) xvi Executive Order #11 http://mn.gov/governorinewsroom/pressreleasedetail.jsp?id= 10288 http://mn.gov/governor/multimedia/pdf/Executive-Order-11-06.pdf XVII DHS Questions on Competitive Bidding (attachment see iv) XVIII Karen Peed Depo. (attachment) xix Matt Anderson (attachment) xx Feldman Depo (attachment) xxi OI-JS Newsletter (attachment) xxii Various Emails from MCHP, DHS, Health Partners, BCBS, Ucare (attachment)


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