HF 3045

1st Engrossment - 89th Legislature (2015 - 2016) Posted on 04/11/2016 04:44pm

A bill for an act
relating to health; modifying provisions for health care quality of care and
complaint investigation process; requiring a report; amending Minnesota Statutes
2014, section 62D.04, subdivision 1; proposing coding for new law in Minnesota
Statutes, chapter 62D.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2014, section 62D.04, subdivision 1, is amended to read:

Subdivision 1.

Application review.

Upon receipt of an application for a certificate
of authority, the commissioner of health shall determine whether the applicant for a
certificate of authority has:

(a) demonstrated the willingness and potential ability to assure that health care
services will be provided in such a manner as to enhance and assure both the availability
and accessibility of adequate personnel and facilities;

(b) arrangements for an ongoing evaluation of the quality of health care new text begin , including a
peer review process new text end ;

(c) a procedure to develop, compile, evaluate, and report statistics relating to the
cost of its operations, the pattern of utilization of its services, the quality, availability and
accessibility of its services, and such other matters as may be reasonably required by
regulation of the commissioner of health;

(d) reasonable provisions for emergency and out of area health care services;

(e) demonstrated that it is financially responsible and may reasonably be expected to
meet its obligations to enrollees and prospective enrollees. In making this determination,
the commissioner of health shall require the amount of initial net worth required in section
62D.042, compliance with the risk-based capital standards under sections 60A.50 to
60A.592, the deposit required in section 62D.041, and in addition shall consider:

(1) the financial soundness of its arrangements for health care services and the
proposed schedule of charges used in connection therewith;

(2) arrangements which will guarantee for a reasonable period of time the continued
availability or payment of the cost of health care services in the event of discontinuance of
the health maintenance organization; and

(3) agreements with providers for the provision of health care services;

(f) demonstrated that it will assume full financial risk on a prospective basis for
the provision of comprehensive health maintenance services, including hospital care;
provided, however, that the requirement in this paragraph shall not prohibit the following:

(1) a health maintenance organization from obtaining insurance or making
other arrangements (i) for the cost of providing to any enrollee comprehensive health
maintenance services, the aggregate value of which exceeds $5,000 in any year, (ii) for
the cost of providing comprehensive health care services to its members on a nonelective
emergency basis, or while they are outside the area served by the organization, or (iii) for
not more than 95 percent of the amount by which the health maintenance organization's
costs for any of its fiscal years exceed 105 percent of its income for such fiscal years; and

(2) a health maintenance organization from having a provision in a group health
maintenance contract allowing an adjustment of premiums paid based upon the actual
health services utilization of the enrollees covered under the contract, except that at no
time during the life of the contract shall the contract holder fully self-insure the financial
risk of health care services delivered under the contract. Risk sharing arrangements shall
be subject to the requirements of sections 62D.01 to 62D.30;

(g) demonstrated that it has made provisions for and adopted a conflict of interest
policy applicable to all members of the board of directors and the principal officers of the
health maintenance organization. The conflict of interest policy shall include the procedures
described in section 317A.255, subdivisions 1 and 2. However, the commissioner is
not precluded from finding that a particular transaction is an unreasonable expense as
described in section 62D.19 even if the directors follow the required procedures; and

(h) otherwise met the requirements of sections 62D.01 to 62D.30.

Sec. 2.

new text begin [62D.115] QUALITY OF CARE COMPLAINTS.
new text end

new text begin Subdivision 1. new text end

new text begin Quality of care complaint. new text end

new text begin For purposes of this section, "quality
of care complaint" means an expressed dissatisfaction regarding the clinical quality of
health care services rendered by a provider, resulting in potential or actual harm to an
enrollee. Quality of care complaints include the following, to the extent that they affect the
clinical quality of health care services rendered: access, provider and staff competence,
appropriateness of care, communications, behavior, facility and environmental
considerations, and other factors that impact the clinical quality of health care services.
new text end

new text begin Subd. 2. new text end

new text begin Quality of care complaint investigation. new text end

new text begin (a) Each health maintenance
organization shall develop and implement policies and procedures for a quality of
care complaint investigation process that meets the requirements of this section. The
health maintenance organization must have a written policy and procedure for receipt,
investigation, and follow-up of quality of care complaints, including the requirements
in paragraphs (b) to (g).
new text end

new text begin (b) The definition of quality of care complaint in the complaint investigation process
must include the concerns identified in subdivision 1.
new text end

new text begin (c) The complaint investigation process must include a description of levels of
severity including:
new text end

new text begin (1) classification of complaints that warrant peer protection confidentiality as defined
by the commissioner under paragraph (h); and
new text end

new text begin (2) investigation procedures for each level of severity.
new text end

new text begin (d) Every complaint with an allegation regarding quality of care or service must be
investigated by the health maintenance organization. Documentation must show every
allegation was addressed.
new text end

new text begin (e) Conclusions must be supported with evidence that may include an associated
corrective action plan implemented and documented and a formal response from a
provider to the health plan. The record of investigation must include all related documents,
correspondence, summaries, discussions, consultations, and conferences held.
new text end

new text begin (f) A medical director review must be conducted when there is potential for patient
harm.
new text end

new text begin (g) Quality of care complaints must be tracked and trended for review according
to provider and type of quality of care issue such as behavior, facility, environmental,
and technical competence.
new text end

new text begin (h) The commissioner, in consultation with any interested stakeholders, shall define
complaints that are subject to peer protection confidentiality in accordance with state and
federal law by January 1, 2018.
new text end

new text begin Subd. 3. new text end

new text begin Complaint reporting. new text end

new text begin Each health maintenance organization shall
submit to the commissioner, as part of the company's annual filing, data on the number
of complaints and the category as defined by the commissioner. Categories shall
include access, communication and behavior, health plan administration, facilities and
environment, coordination of care, and technical competence and appropriateness.
The commissioner shall define complaint categories in consultation with interested
stakeholders by January 1, 2018.
new text end

new text begin Subd. 4. new text end

new text begin Record keeping. new text end

new text begin Each health maintenance organization shall maintain
records of all quality of care complaints and their resolutions. These records shall be
retained for five years and, notwithstanding section 145.64, shall be made available to
the commissioner upon request. Information provided to the commissioner according to
this subdivision shall be classified as confidential data on individuals as defined in section
13.02, subdivision 3.
new text end