HF 1850

as introduced - 89th Legislature (2015 - 2016) Posted on 03/12/2015 02:11pm

A bill for an act
relating to commerce; establishing continued care at home contracts; requiring
providers to prove financial responsibility to the commissioner of commerce;
amending Minnesota Statutes 2014, section 609.232, subdivision 11; proposing
coding for new law as Minnesota Statutes, chapter 80H.

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

Section 1.

new text begin [80H.01] CONTINUING CARE AT HOME PROGRAM; PURPOSE
AND GOALS.
new text end

new text begin The legislature finds that the following objectives may be further enhanced through
the establishment and promotion of continuing care at home providers:
new text end

new text begin (1) enabling persons to age in place in their own homes as independently and
as long as possible;
new text end

new text begin (2) enhancing private funding of long-term support services;
new text end

new text begin (3) enabling persons to plan for their future potential need for long-term care and
support services;
new text end

new text begin (4) reducing or containing medical assistance expenditures; and
new text end

new text begin (5) reducing or forestalling placements at nursing facilities and assisted living
facilities.
new text end

Sec. 2.

new text begin [80H.02] DEFINITIONS.
new text end

new text begin Subdivision 1. new text end

new text begin Applicability. new text end

new text begin For purposes of this chapter, the terms defined in this
section have the meanings given to them.
new text end

new text begin Subd. 2. new text end

new text begin Affiliated with. new text end

new text begin "Affiliated with" means a common ownership or control
with a licensed health care provider.
new text end

new text begin Subd. 3. new text end

new text begin Ancillary services. new text end

new text begin (a) "Ancillary services" may include care coordination,
care management, wellness programs, health assessments, health information analysis,
necessary referrals to independent providers, home safety evaluations, homemaker
services, personal emergency response systems, smart-home technology services, physical
accessibility enhancements, and chronic disease management.
new text end

new text begin (b) Ancillary services are covered by the premiums charged under the CCaH plan
and may not be billed separately. Ancillary services must commence upon the effective
date of the participant's CCaH plan.
new text end

new text begin Subd. 4. new text end

new text begin Care coordination. new text end

new text begin "Care coordination" means developing and
implementing a plan of care to address the participant's needs throughout the participant's
enrollment in the CCaH plan. This includes, but is not limited to, assisting a participant
to access benefits available through third party payors including Medicare, medical
assistance, waivered services, or private insurance plans, and to coordinate those benefits
with the core and ancillary services provided under the CCaH plan.
new text end

new text begin Subd. 5. new text end

new text begin Common ownership or control. new text end

new text begin "Common ownership or control" means
a CCaH provider and licensed health provider are:
new text end

new text begin (1) owned or operated by the same person, corporation, limited liability company,
or partnership;
new text end

new text begin (2) subsidiaries of a common parent corporate organization;
new text end

new text begin (3) operated under management agreements with a single managing entity;
new text end

new text begin (4) governed by directors, officers, partners, or members appointed by a single
organization; or
new text end

new text begin (5) directly related by other operation of laws.
new text end

new text begin Subd. 6. new text end

new text begin Continuing care at home plan. new text end

new text begin "Continuing care at home plan" or "CCaH
plan" means an enrollment arrangement between a participant and a CCaH provider
wherein the CCaH provider provides long-term care and support core services and
ancillary services in accordance with this chapter once a participant becomes eligible to
claim and receive services, effective up to the maximum benefit amount purchased by a
participant. Enrollment in a CCaH plan shall be:
new text end

new text begin (1) pursuant to a CCaH contract between the CCaH provider and a participant that
meets the terms and conditions of section 80H.03;
new text end

new text begin (2) provided in consideration of a participant's payment of established premiums to
the CCaH provider. Premiums shall be charged by the CCaH provider on a monthly basis,
but a participant may elect to pay the CCaH plan premium either monthly, annually, or
quarterly, so long as the participant has selected the participant's payment option in the
CCaH contract, or any subsequent amendment thereto; and
new text end

new text begin (3) available to qualified applicants between the ages of 50 and 80, whose further
qualifications for eligibility under the CCaH plan are subject to independent underwriting
and evaluations of the applicant's health status based on information produced by the
applicant during the application process. The applicant may be required to provide a
written application disclosing relevant personal data including medical and familial health
history and medical records from the applicant's physicians or other health providers.
The application process may include personal interviews, mental and physical health
examinations, or clinical nursing assessments. The CCaH provider and any designee must
comply with the Health Insurance Portability and Accountability Act of 1996 and its
implementing regulations, and all applicable requirements with respect to all protected
health information obtained during the application process, whether or not the applicant
enrolls in the CCaH plan.
new text end

new text begin Subd. 7. new text end

new text begin Continuing care at home provider. new text end

new text begin "Continuing care at home provider"
or "CCaH provider" means a corporation, limited liability company, or partnership that
meets the financial responsibility requirements of section 80H.04, subdivision 2, offers to
provide core services to enrolled participants under a CCaH plan, and is affiliated with
two or more licensed health care providers.
new text end

new text begin Subd. 8. new text end

new text begin Core services. new text end

new text begin (a) "Core services" which may be offered in a CCaH
plan are long-term care and support services defined under sections 144A.02, 144A.46,
144A.75 to 144A.755, 245A.01 to 245A.16, and chapters 144D and 245D. Core services
do not replace any benefits that may be otherwise available to a participant from
third-party payors, including, but not limited to, Medicare, medical assistance, waivered
services, or private insurance, and are offered in addition to and separate from those
benefits. Except as provided in paragraph (c), a core service available under a participant's
CCaH plan shall only be provided through the licensed health care providers affiliated
with the CCaH provider.
new text end

new text begin (b) Core services are covered by the premiums charged under the CCaH plan and may
not be billed separately. Core services must commence at the end of the elimination period.
new text end

new text begin (c) If offered in good faith for the participant's benefit and if reasonable and
necessary to meet the participant's need for core services, the CCaH provider may elect
to provide, at its sole option, a core service through a licensed health care provider not
affiliated with the CCaH provider. The CCaH provider must enter into a participating
provider contract with the unaffiliated health care provider. The unaffiliated licensed
health care provider shall not charge the participant for core service. The participating
provider contract shall obligate the CCaH provider to pay for the participant's core
services at a negotiated payment rate mutually acceptable to the CCaH provider and the
unaffiliated licensed health care provider. The CCaH provider shall have and maintain
access to the participant's health data for purposes of coordinating the participant's care.
The CCaH provider shall not engage unaffiliated licensed health care providers solely for
the CCaH provider's convenience. Engaging an unaffiliated licensed health care provider
shall not be grounds for a premium increase.
new text end

new text begin Subd. 9. new text end

new text begin Elimination period. new text end

new text begin "Elimination period" means a number of days, weeks,
or months specified in the CCaH plan and commences at the beginning of each period
of the participant's confirmed need. Core services are provided upon the conclusion of
the elimination period. Ancillary services continue throughout the elimination period,
and the care coordinator shall assist the participant in finding necessary home health or
long-term care services during the elimination period either at the participant's expense, or
as covered by Medicare, medical assistance, or private insurance.
new text end

new text begin Subd. 10. new text end

new text begin Home. new text end

new text begin "Home" means the participant's place of residence, including
independent senior living apartment buildings, regardless of ownership.
new text end

new text begin Subd. 11. new text end

new text begin Licensed health care provider. new text end

new text begin "Licensed health care provider" means:
new text end

new text begin (1) a nursing home licensed to serve adults under section 144A.02;
new text end

new text begin (2) a home care provider licensed under section 144A.46;
new text end

new text begin (3) a housing with services site registered under chapter 144D;
new text end

new text begin (4) a hospice provider licensed under sections 144A.75 to 144A.755;
new text end

new text begin (5) an organization authorized to provide personal care assistance or basic support
services licensed under chapter 245D; or
new text end

new text begin (6) a residential or nonresidential facility required to be licensed to service adults
under sections 245A.01 to 245A.16.
new text end

new text begin Subd. 12. new text end

new text begin Maximum benefit amount. new text end

new text begin "Maximum benefit amount" means the
maximum dollar amount established by the CCaH plan. The CCaH provider will assure
or provide core and ancillary services up to the maximum benefit amount upon the
participant's initial and continued need and eligibility to claim and receive such services.
Participants shall select daily and maximum total benefit amounts upon enrollment.
new text end

new text begin Subd. 13. new text end

new text begin Participant. new text end

new text begin (a) "Participant" means an individual who has been accepted
for enrollment in a CCaH plan and who enters into an enrollment contract with a CCaH
provider and who agrees to pay the premiums from the participant's private resources.
new text end

new text begin (b) A participant may also include any individual, including a medical assistance
program or home and community-based waiver recipient, who has a third-party payor,
such as a supportive family member, enter into the CCaH plan to be directly responsible
for paying the premium on the participant's behalf. The amount paid by a third-party payor
shall not be included in the participant's income for purposes of evaluating the participant's
eligibility for any medical assistance or waiver program.
new text end

new text begin Subd. 14. new text end

new text begin Premium. new text end

new text begin "Premium" means the amount charged by the CCaH provider
to maintain the participant's enrollment in the CCaH plan. The premium need not be
guaranteed and may be adjusted by the CCaH provider in accordance with the terms of the
CCaH plan. The premium charged shall cover all payments due to the CCaH provider
for core and ancillary services.
new text end

new text begin Subd. 15. new text end

new text begin Private resources. new text end

new text begin "Private resources" means the liquid financial assets
of the participant or any third-party payor who agrees, in writing, to pay the premiums
and charges for core, ancillary, or supplemental services. A CCaH provider shall not take
a reverse mortgage or other equitable interest in a home or other asset owned by the
participant as payment for the premium during the participant's enrollment in the CCaH
plan.
new text end

new text begin Subd. 16. new text end

new text begin Supplemental services. new text end

new text begin "Supplemental services" are arranged, reviewed,
and recommended by the CCaH provider at the request of the participant through
independent vendors and are charged to the participant separately from the premium.
Supplemental services shall not include core or ancillary services, but may include
arranging contracts with qualified vendors to provide necessary repairs, improvements, or
accessibility upgrades to a participant's home or furnishings, or routine home maintenance
needs. Supplemental services, including the nature, scope, and estimated cost, must be
offered in advance for the participant's prior authorization.
new text end

Sec. 3.

new text begin [80H.03] CONTINUING CARE AT HOME CONTRACT.
new text end

new text begin Subdivision 1. new text end

new text begin Continuing care at home contract. new text end

new text begin (a) A continuing care at home
contract provided under a CCaH plan between a CCaH provider and a participant shall
describe:
new text end

new text begin (1) the maximum benefit amount and any daily benefit limit;
new text end

new text begin (2) the premium;
new text end

new text begin (3) the benefits provided, including:
new text end

new text begin (i) the core services selected by the participant;
new text end

new text begin (ii) the ancillary services selected by the participant;
new text end

new text begin (iii) the level of initial and continued need necessary to trigger a participant's access
to core services, including, if applicable, the number of daily living activities that a
participant is unable to perform;
new text end

new text begin (iv) the level of a participant's improvement required to cease or modify commenced
core services safely; and
new text end

new text begin (v) the geographical limits on the CCaH provider's services area;
new text end

new text begin (4) the elimination period;
new text end

new text begin (5) the notification required for premium increase, which shall not be less than
30 days;
new text end

new text begin (6) the option of a fixed premium for a period not greater than five years;
new text end

new text begin (7) the option of a premium discount of up to 20 percent for cohabitants enrolling
contemporaneously as participants;
new text end

new text begin (8) the application fee, which shall not exceed $100, and which shall be fully
refunded to the applicant if the applicant does not pass underwriting or if the applicant
elects not to enroll in a CCaH plan;
new text end

new text begin (9) termination requirements for both the participant and the CCaH provider as
provided in subdivision 3;
new text end

new text begin (10) a description of supplemental services available through the CCaH provider for
payment of an additional charge;
new text end

new text begin (11) the terms by which a CCaH provider may offer, and a participant may accept:
new text end

new text begin (i) additional core services or ancillary services;
new text end

new text begin (ii) inflation protection for the daily benefit limit; and
new text end

new text begin (iii) a survivorship provision that transfers a participant's unused maximum benefit
amount to a surviving spouse who is also a participant;
new text end

new text begin (12) that the CCaH provider is authorized to require the participant to use additional
core services as provided in subdivision 2; and
new text end

new text begin (13) a grievance procedure enabling the participant to submit written grievances
regarding the provision of core or ancillary services as described in subdivision 4.
new text end

new text begin (b) The contract must also include provisions explaining what must occur if a
participant chooses a nonplan participating provider within the plan's designated service
area. If a patient makes this choice, the participant shall agree to pay for the services and
submit documentation to the CCaH provider on the delivery of care and payment for the
care. The CCaH provider must then reimburse the participant for the lesser of the amount
paid by the participant for the care provided or the CCaH provider's average cost of care
provided by a plan participating provider for any such services up to the maximum daily
benefit in the participant's agreement.
new text end

new text begin Subd. 2. new text end

new text begin CCaH provider's authority to require additional core services. new text end

new text begin (a) A
CCaH provider is authorized to require the participant to use additional core services
that are available under the maximum benefit amount, including, but not limited to,
transferring the participant to a licensed assisted living or skilled nursing facility arranged
by the CCaH provider, in order to prevent either:
new text end

new text begin (1) the participant's self-neglect as defined by section 626.5572, subdivision 17,
paragraph (b); or
new text end

new text begin (2) the participant from being unsafe to others in the community or from harming
any other vulnerable adult as defined by section 626.5572, subdivision 21.
new text end

new text begin (b) The CCaH provider shall consult with and consider recommendations of the
participant's primary care physician unless the participant refuses to cooperate with the
physician. The CCaH provider shall evaluate the participant's number of activities of daily
living dependencies and the supports necessary to remain living at home before requiring
additional services.
new text end

new text begin Subd. 3. new text end

new text begin Contract termination procedures. new text end

new text begin (a) A participant may terminate a
contract with a CCaH provider with 30 days' written notice to the CCaH provider. A
participant may terminate the contract for any reason, including, but not limited to, the
participant's dissatisfaction with care recommendations, premium increases, or because
the participant is relocating outside the service areas covered by the CCaH provider.
new text end

new text begin (b) A CCaH provider may terminate a contract with a participant only for good
cause. Good cause shall be limited to any of the following:
new text end

new text begin (1) nonpayment of premiums;
new text end

new text begin (2) a participant's continued and repeated refusal to participate in medical
examinations or other evaluations arranged by the CCaH provider's care coordinator,
thereby causing reasonable concern that the participant may not be claiming or receiving
necessary core services;
new text end

new text begin (3) the participant's refusal to accept the additional core services identified by the
CCaH provider pursuant to subdivision 2;
new text end

new text begin (4) the participant's continued and repeated noncompliance with the care
recommendations and directives of the CCaH provider or licensed health professional
engaged by the CCaH provider;
new text end

new text begin (5) a material misrepresentation made intentionally or recklessly by the participant
or the participant's representative during the application process for enrollment or the
failure to produce related materials and information which, if provided in a timely manner,
would have resulted in either the applicant's rejection for enrollment or in a material
increase in the cost of the offered premium; or
new text end

new text begin (6) the participant's material breach of the terms and conditions under the contract.
new text end

new text begin (c) A CCaH provider must give a participant notice of the grounds for termination
under paragraph (b) and give the participant a reasonable opportunity to cure, not to exceed
30 days. The opportunity to cure shall not prevent the CCaH provider from immediately
notifying the lead investigative agency if the CCaH provider has reason to believe the
participant is subject to self-neglect under section 626.5572, subdivision 17, paragraph (b).
new text end

new text begin (d) The contract between a CCaH provider and a participant and the participant's
enrollment in a CCaH plan terminates upon the exhaustion of the maximum benefit
amount or the death of the participant, whichever is earlier.
new text end

new text begin (e) Upon proper notice of termination under this subdivision or upon the death
of the participant, the CCaH provider shall refund, pro rata, any prepaid premium to
the participant or the participant's estate.
new text end

new text begin Subd. 4. new text end

new text begin Grievances. new text end

new text begin Written grievances may be filed by a participant to a CCaH
provider regarding any service or concern regarding the participant's agreement with a
CCaH provider. Grievances shall be filed with and acted upon by the CCaH provider's
director of care coordination. If unresolved within ten business days, the grievance shall
be forwarded to the executive director of the CCaH provider for final review and action.
Nothing in this subdivision alters the participant's right to report suspected maltreatment
under section 626.557 or limits the participant's rights under section 144.651, if applicable.
new text end

Sec. 4.

new text begin [80H.04] CONTINUING CARE AT HOME PROVIDER
QUALIFICATIONS.
new text end

new text begin Subdivision 1. new text end

new text begin Provision of services. new text end

new text begin (a) A CCaH provider may provide core
services only through affiliated or unaffiliated licensed health care providers, as established
in section 80H.02, subdivision 8.
new text end

new text begin (b) A CCaH provider may arrange for supplemental services and may provide
nonhealth care goods and services through vendors on a transactional basis for fees in
addition to premiums paid.
new text end

new text begin (c) An employee of a CCaH provider who has direct contact with a participant is
subject to a background study under chapter 245C and the CCaH provider shall submit
that employee for a background study, unless that employee has already obtained a
background study clearance as a result of a submission by a licensed health care provider
affiliated with the CCaH provider.
new text end

new text begin (d) Care coordination provided under ancillary services may either be performed by
licensed professionals, including registered nurses or licensed clinical social workers, or
at a licensed professional's direction by unlicensed staff. Unlicensed staff coordinating
care under supervision must have a college degree and must demonstrate to the CCaH
provider's satisfaction that the unlicensed person has completed training in case
management and coordination in long-term care and support.
new text end

new text begin Subd. 2. new text end

new text begin Proof of financial responsibility. new text end

new text begin (a) A CCaH provider shall either:
new text end

new text begin (1) annually file with the commissioner of commerce a performance bond or
equivalent proof of financial responsibility in the amount equal to the total of all
participant premiums collected, as adjusted annually for usage, refunds, or subsequent
entrance fee collection; or
new text end

new text begin (2) if the CCaH provider is affiliated with an organization with assets greater than
$25,000,000, the CCaH provider may file with the commissioner a financial guarantee
executed by the affiliated organization that guarantees payment of an amount equivalent to
the refund of any unused portion of the premium due to a participant for any reason.
new text end

new text begin (b) On an annual basis, a CCaH provider shall make available to participants reviews
conducted by independent actuaries and audits by its independent certified public accounts.
new text end

new text begin Subd. 3. new text end

new text begin Disclosure statement. new text end

new text begin A CCaH provider shall annually file a disclosure
statement with the commissioner that identifies the members or owners of the CCaH and
includes a template of its CCaH contract and a list of participating health care providers,
whether affiliated or unaffiliated.
new text end

new text begin Subd. 4. new text end

new text begin Confidentiality. new text end

new text begin A CCaH provider must comply with the Health Insurance
Portability and Accountability Act of 1996 and its implementing regulations and all
applicable requirements with respect to all protected health information obtained,
including the Minnesota Health Records Act.
new text end

Sec. 5.

new text begin [80H.05] CONTINUING CARE AT HOME EXEMPTIONS.
new text end

new text begin CCaH plans and contracts under this chapter are not Medicare gap supplemental
insurance policies and the CCaH services defined and offered are separate from, and in
addition to, any insurance or Medicare coverage for which a participant may be eligible.
CCaH plans offered under this chapter are not contracts of insurance and CCaH programs
are exempt from the general insurance powers of chapter 60A and the laws governing
health maintenance organizations and managed care organizations. CCaH providers are
not continuing care facilities under chapter 80D.
new text end

Sec. 6.

new text begin [80H.06] MANDATED REPORTERS.
new text end

new text begin Employees of a CCaH provider who have direct contact with participants
are mandated reporters under section 626.5572, subdivision 16. When conducting
maltreatment investigations under section 626.557, subdivision 9, the lead agency for the
licensed health care provider may review and assess the responsibility of a CCaH provider
for substantiated maltreatment under section 626.557, subdivision 9c.
new text end

Sec. 7.

Minnesota Statutes 2014, section 609.232, subdivision 11, is amended to read:

Subd. 11.

Vulnerable adult.

"Vulnerable adult" means any person 18 years of
age or older who:

(1) is a resident inpatient of a facility;

(2) receives services at or from a facility required to be licensed to serve adults
under sections 245A.01 to 245A.15, except that a person receiving outpatient services for
treatment of chemical dependency or mental illness, or one who is committed as a sexual
psychopathic personality or as a sexually dangerous person under chapter 253B, is not
considered a vulnerable adult unless the person meets the requirements of clause (4);

(3) receives services from a home care provider required to be licensed under section
144A.46 deleted text begin ; or deleted text end new text begin , new text end from a person or organization that exclusively offers, provides, or arranges
for personal care assistance services under the medical assistance program as authorized
under sections 256B.0625, subdivision 19a, 256B.0651 to 256B.0654, and 256B.0659 new text begin , or
from a continuing care at home provider as established under chapter 80H new text end ; or

(4) regardless of residence or whether any type of service is received, possesses a
physical or mental infirmity or other physical, mental, or emotional dysfunction:

(i) that impairs the individual's ability to provide adequately for the individual's
own care without assistance, including the provision of food, shelter, clothing, health
care, or supervision; and

(ii) because of the dysfunction or infirmity and the need for assistance, the individual
has an impaired ability to protect the individual from maltreatment.