HF 3610

as introduced - 81st Legislature (1999 - 2000) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to health; providing patient protections; 
  1.3             requiring coverage for medical clinical trials; 
  1.4             amending Minnesota Statutes 1998, sections 62D.17, 
  1.5             subdivision 1; 62J.38; 62Q.56; and 62Q.58; Minnesota 
  1.6             Statutes 1999 Supplement, section 45.027, subdivision 
  1.7             6; proposing coding for new law in Minnesota Statutes, 
  1.8             chapter 62Q.  
  1.9   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.10     Section 1.  Minnesota Statutes 1999 Supplement, section 
  1.11  45.027, subdivision 6, is amended to read: 
  1.12     Subd. 6.  [VIOLATIONS AND PENALTIES.] The commissioner may 
  1.13  impose a civil penalty not to exceed $10,000 per violation upon 
  1.14  a person who violates any law, rule, or order related to the 
  1.15  duties and responsibilities entrusted to the commissioner unless 
  1.16  a different penalty is specified.  If a civil penalty is imposed 
  1.17  on a health carrier as defined in section 62A.011, the 
  1.18  commissioner must divide 50 percent of the amount among any 
  1.19  policy holder or certificate holder affected by the violation.  
  1.20     Sec. 2.  Minnesota Statutes 1998, section 62D.17, 
  1.21  subdivision 1, is amended to read: 
  1.22     Subdivision 1.  The commissioner of health may, for any 
  1.23  violation of statute or rule applicable to a health maintenance 
  1.24  organization, or in lieu of suspension or revocation of a 
  1.25  certificate of authority under section 62D.15, levy an 
  1.26  administrative penalty in an amount up to $25,000 for each 
  1.27  violation.  In the case of contracts or agreements made pursuant 
  2.1   to section 62D.05, subdivisions 2 to 4, each contract or 
  2.2   agreement entered into or implemented in a manner which violates 
  2.3   sections 62D.01 to 62D.30 shall be considered a separate 
  2.4   violation.  In determining the level of an administrative 
  2.5   penalty, the commissioner shall consider the following factors: 
  2.6      (1) the number of enrollees affected by the violation; 
  2.7      (2) the effect of the violation on enrollees' health and 
  2.8   access to health services; 
  2.9      (3) if only one enrollee is affected, the effect of the 
  2.10  violation on that enrollee's health; 
  2.11     (4) whether the violation is an isolated incident or part 
  2.12  of a pattern of violations; and 
  2.13     (5) the economic benefits derived by the health maintenance 
  2.14  organization or a participating provider by virtue of the 
  2.15  violation. 
  2.16     Reasonable notice in writing to the health maintenance 
  2.17  organization shall be given of the intent to levy the penalty 
  2.18  and the reasons therefor, and the health maintenance 
  2.19  organization may have 15 days within which to file a written 
  2.20  request for an administrative hearing and review of the 
  2.21  commissioner of health's determination.  Such administrative 
  2.22  hearing shall be subject to judicial review pursuant to chapter 
  2.23  14.  If an administrative penalty is levied, the commissioner 
  2.24  must divide 50 percent of the amount among any enrollee affected 
  2.25  by the violation. 
  2.26     Sec. 3.  Minnesota Statutes 1998, section 62J.38, is 
  2.27  amended to read: 
  2.28     62J.38 [COST CONTAINMENT DATA FROM GROUP PURCHASERS.] 
  2.29     (a) The commissioner shall require group purchasers to 
  2.30  submit detailed data on total health care spending for each 
  2.31  calendar year.  Group purchasers shall submit data for the 1993 
  2.32  calendar year by April 1, 1994, and each April 1 thereafter 
  2.33  shall submit data for the preceding calendar year. 
  2.34     (b) The commissioner shall require each group purchaser to 
  2.35  submit data on revenue, expenses, and member months, as 
  2.36  applicable.  Revenue data must distinguish between premium 
  3.1   revenue and revenue from other sources and must also include 
  3.2   information on the amount of revenue in reserves and changes in 
  3.3   reserves.  Expenditure data, including raw data from claims, may 
  3.4   must distinguish between expenses incurred for patient care and 
  3.5   administrative costs.  Expenditure data must be provided 
  3.6   separately for the following categories or and for other 
  3.7   categories required by the commissioner:  physician services, 
  3.8   dental services, other professional services, inpatient hospital 
  3.9   services, outpatient hospital services, emergency, pharmacy 
  3.10  services and other nondurable medical goods, mental health, and 
  3.11  chemical dependency services, other expenditures, subscriber 
  3.12  liability, and administrative costs.  Administrative costs shall 
  3.13  include costs for marketing; advertising; overhead; 
  3.14  underwriting; lobbying; claims processing; provider contracting 
  3.15  and credentialing; detection and prevention of payment for 
  3.16  fraudulent or unjustified requests for reimbursement or 
  3.17  services; clinical quality assurance and other types of medical 
  3.18  care quality improvement efforts; concurrent or prospective 
  3.19  utilization review as defined in section 62M.02; payments made 
  3.20  to acquire a hospital, clinic, health care facility, or the 
  3.21  assets thereof; capital costs paid on behalf of a hospital or 
  3.22  clinic; lease payments; or any other payment made to a hospital, 
  3.23  clinic, or other health care provider pursuant to a partnership, 
  3.24  joint venture, integration, or affiliation agreement.  The 
  3.25  commissioner may require each group purchaser to submit any 
  3.26  other data, including data in unaggregated form, for the 
  3.27  purposes of developing spending estimates, setting spending 
  3.28  limits, and monitoring actual spending and costs. 
  3.29     (c) The commissioner may collect information on: 
  3.30     (1) premiums, benefit levels, managed care procedures, and 
  3.31  other features of health plan companies; 
  3.32     (2) prices, provider experience, and other information for 
  3.33  services less commonly covered by insurance or for which 
  3.34  patients commonly face significant out-of-pocket expenses; and 
  3.35     (3) information on health care services not provided 
  3.36  through health plan companies, including information on prices, 
  4.1   costs, expenditures, and utilization. 
  4.2      (d) All group purchasers shall provide the required data 
  4.3   using a uniform format and uniform definitions, as prescribed by 
  4.4   the commissioner. 
  4.5      Sec. 4.  Minnesota Statutes 1998, section 62Q.56, is 
  4.6   amended to read: 
  4.7      62Q.56 [CONTINUITY OF CARE.] 
  4.8      Subdivision 1.  [CHANGE IN HEALTH CARE PROVIDER.] (a) If 
  4.9   enrollees are required to access services through selected 
  4.10  primary care providers for coverage, the health plan company 
  4.11  shall prepare a written plan that provides for continuity of 
  4.12  care in the event of contract termination between the health 
  4.13  plan company and any of the contracted primary care providers or 
  4.14  general hospital providers.  The written plan must explain: 
  4.15     (1) how the health plan company will inform affected 
  4.16  enrollees, insureds, or beneficiaries about termination at least 
  4.17  30 days before the termination is effective, if the health plan 
  4.18  company or health care network cooperative has received at least 
  4.19  120 days' prior notice; 
  4.20     (2) how the health plan company will inform the affected 
  4.21  enrollees about what other participating providers are available 
  4.22  to assume care and how it will facilitate an orderly transfer of 
  4.23  its enrollees from the terminating provider to the new provider 
  4.24  to maintain continuity of care; 
  4.25     (3) the procedures by which enrollees will be transferred 
  4.26  to other participating providers, when special medical needs, 
  4.27  special risks, or other special circumstances, such as cultural 
  4.28  or language barriers, require them to have a longer transition 
  4.29  period or be transferred to nonparticipating providers; 
  4.30     (4) who will identify enrollees with special medical needs 
  4.31  or at special risk and what criteria will be used for this 
  4.32  determination; and 
  4.33     (5) how continuity of care will be provided for enrollees 
  4.34  identified as having special needs or at special risk, and 
  4.35  whether the health plan company has assigned this responsibility 
  4.36  to its contracted primary care providers. 
  5.1      (b) If the contract termination was not for cause, 
  5.2   enrollees can request a referral to the terminating provider for 
  5.3   up to 120 days if they have special medical needs or have other 
  5.4   special circumstances, such as cultural or language barriers.  
  5.5   The health plan company can require medical records and other 
  5.6   supporting documentation in support of the requested referral.  
  5.7   Each request for referral to a terminating provider shall be 
  5.8   considered by the health plan company on a case-by-case basis a 
  5.9   health plan company must continue to provide coverage for all 
  5.10  covered services provided by the terminating provider to an 
  5.11  enrollee if at the time of termination the provider is providing 
  5.12  a covered service to the enrollee for an ongoing course of 
  5.13  treatment.  Coverage for the services provided by the 
  5.14  terminating provider shall continue until the end of the 
  5.15  treatment. 
  5.16     (c) If the contract termination was for cause, enrollees 
  5.17  must be notified of the change and transferred to participating 
  5.18  providers in a timely manner so that health care services remain 
  5.19  available and accessible to the affected enrollees.  The health 
  5.20  plan company is not required to refer an enrollee back to the 
  5.21  terminating provider if the termination was for cause. 
  5.22     Subd. 2.  [CHANGE IN HEALTH PLANS.] (a) The A health plan 
  5.23  company shall prepare a written plan that provides a process for 
  5.24  provide coverage determinations for continuity of care for a new 
  5.25  enrollees with special needs, special risks, or other special 
  5.26  circumstances, such as cultural or language barriers, enrollee 
  5.27  who request requests continuity of care with their the 
  5.28  enrollee's former provider for up to 120 days.  The written plan 
  5.29  must explain the criteria that will be used for determining 
  5.30  special needs cases, and how continuity of care will be 
  5.31  provided. if at the time of enrollment the enrollee is receiving 
  5.32  an ongoing course of treatment from the former provider and the 
  5.33  enrollee meets one of the following conditions:  
  5.34     (1) has a life-threatening physical condition, mental 
  5.35  condition, or chronic health care condition; 
  5.36     (2) has a degenerative disease, physical disability, mental 
  6.1   illness, chronic health care condition, or mental retardation or 
  6.2   other related conditions; 
  6.3      (3) has entered the second trimester of pregnancy prior to 
  6.4   the time of enrollment; 
  6.5      (4) is receiving culturally appropriate services and the 
  6.6   health plan company does not have a provider in its preferred 
  6.7   provider network with special expertise in the delivery of these 
  6.8   culturally appropriate services within the time and distance 
  6.9   requirements of section 62D.124, subdivision 1; or 
  6.10     (5) does not speak English and the health plan company does 
  6.11  not have a provider in its preferred provider network that 
  6.12  speaks the language spoken by the enrollee within the time and 
  6.13  distance requirements of section 62D.124, subdivision 1.  
  6.14     (b) This subdivision applies only to group coverage and 
  6.15  continuation and conversion coverage, and applies only to 
  6.16  changes in health plans made by the employer. 
  6.17     Subd. 2a.  [LIMITATIONS.] (a) Subdivisions 1 and 2 apply 
  6.18  only if the enrollee's health care provider agrees to: 
  6.19     (1) accept as payment in full the health plan company's 
  6.20  reimbursement rate for in-network providers for the same or 
  6.21  similar service; 
  6.22     (2) adhere to the health plan company's preauthorization 
  6.23  requirements; and 
  6.24     (3) provide the health plan company with all necessary 
  6.25  medical information related to the care provided to the enrollee.
  6.26     (b) Nothing in this section requires a health plan company 
  6.27  to provide coverage for a health care service or treatment that 
  6.28  is not covered under the enrollee's health plan.  
  6.29     Subd. 3.  [DISCLOSURES DISCLOSURE.] The written plans 
  6.30  required under this section must be made available upon request 
  6.31  to enrollees or prospective enrollees.  Information regarding an 
  6.32  enrollee's rights under this section must be included in direct 
  6.33  marketing materials and in member contracts or certificates of 
  6.34  coverage and must be provided by a health plan company upon 
  6.35  request of an enrollee or prospective enrollee.  
  6.36     Sec. 5.  Minnesota Statutes 1998, section 62Q.58, is 
  7.1   amended to read: 
  7.2      62Q.58 [ACCESS TO SPECIALTY CARE.] 
  7.3      Subdivision 1.  [STANDING REFERRAL.] A health plan company 
  7.4   shall establish a procedure by which an enrollee may apply 
  7.5   for and, if appropriate, receive a standing referral to a health 
  7.6   care provider who is a specialist if a referral to a specialist 
  7.7   is required for coverage.  This procedure for a standing 
  7.8   referral must specify the necessary criteria and conditions, 
  7.9   which must be met in order for an enrollee to obtain a standing 
  7.10  referral managed care review and approval an enrollee must 
  7.11  obtain before such a standing referral is permitted. 
  7.12     Subd. 1a.  [MANDATORY STANDING REFERRAL.] An enrollee who 
  7.13  requests a standing referral to a specialist qualified to treat 
  7.14  the specific condition described in clauses (1) to (3) must be 
  7.15  given a standing referral to such a specialist if the enrollee 
  7.16  meets any of the following conditions:  
  7.17     (1) has a life-threatening physical condition, mental 
  7.18  condition, or chronic health care condition requiring ongoing 
  7.19  visits to a specialist; 
  7.20     (2) has a degenerative disease, physical disability, mental 
  7.21  illness, chronic health care condition, or mental retardation or 
  7.22  other related conditions; or 
  7.23     (3) has entered the second trimester of pregnancy and the 
  7.24  pregnancy has been assessed by the health plan company as high 
  7.25  risk.  
  7.26     Subd. 2.  [COORDINATION OF SERVICES.] A primary care 
  7.27  provider or primary care group shall remain responsible for 
  7.28  coordinating the care of an enrollee who has received a standing 
  7.29  referral to a specialist.  The specialist shall not make any 
  7.30  secondary referrals related to primary care services without 
  7.31  prior approval by the primary care provider or primary care 
  7.32  group.  However, An enrollee with a standing referral to a 
  7.33  specialist may request primary care services from that 
  7.34  specialist that the specialist become the enrollee's primary 
  7.35  care provider and manage all medical care appropriate to the 
  7.36  enrollee.  The specialist, in agreement with the enrollee and 
  8.1   primary care provider or primary care group, may elect to 
  8.2   provide primary care services to that the enrollee, authorize 
  8.3   tests and services, and make secondary referrals according to 
  8.4   procedures established by the health plan company.  
  8.5      Subd. 3.  [DISCLOSURE.] Information regarding referral 
  8.6   procedures under this section must be included in any direct 
  8.7   marketing materials and in member contracts or certificates of 
  8.8   coverage and must be provided to an enrollee or prospective 
  8.9   enrollee by a health plan company upon request. 
  8.10     Sec. 6.  [62Q.75] [MEDICAL CLINICAL TRIALS.] 
  8.11     Subdivision 1.  [DEFINITIONS.] For purposes of this 
  8.12  section, "patient cost" means the cost of a medically necessary 
  8.13  health care service that is incurred as a result of treatment 
  8.14  being provided to an enrollee for the purpose of a clinical 
  8.15  trial.  Patient cost does not include: 
  8.16     (1) the cost of an investigational drug or device; 
  8.17     (2) the cost of a non-health care service that an enrollee 
  8.18  may be required to receive as a result of treatment being 
  8.19  provided for the purposes of a clinical trial; 
  8.20     (3) costs associated with managing the research associated 
  8.21  with a clinical trial; or 
  8.22     (4) costs that would not be covered under the enrollee's 
  8.23  health plan. 
  8.24     Subd. 2.  [COVERAGE REQUIRED.] A health plan company shall 
  8.25  provide coverage for patient costs incurred by an enrollee in a 
  8.26  clinical trial as a result of treatment provided for a 
  8.27  life-threatening condition or prevention, early detection, and 
  8.28  treatment studies on cancer if: 
  8.29     (1) the treatment is being provided or the studies are 
  8.30  being conducted in a phase I, phase II, phase III, or phase IV 
  8.31  clinical trial for cancer, or the treatment is being provided in 
  8.32  a phase II, phase III, or phase IV clinical trial for any other 
  8.33  life-threatening condition; 
  8.34     (2) the treatment is being provided in a clinical trial 
  8.35  approved by: 
  8.36     (i) the National Institute of Health; 
  9.1      (ii) a cooperative group or center of the National 
  9.2   Institute of Health; 
  9.3      (iii) the federal Food and Drug Administration in the form 
  9.4   of an investigational new drug application; 
  9.5      (iv) the federal Department of Veterans Affairs; 
  9.6      (v) the federal Department of Defense; 
  9.7      (vi) a qualified research entity that meets the criteria 
  9.8   for the center of the National Institute of Health support grant 
  9.9   eligibility; or 
  9.10     (vii) a panel of qualified recognized experts in clinical 
  9.11  research within an academic institution in the state; 
  9.12     (3) the proposed treatment has been reviewed and approved 
  9.13  by a qualified institutional review board; and 
  9.14     (4) the facility and personnel providing the treatment are 
  9.15  providing treatment within their scope of practice, experience, 
  9.16  and training. 
  9.17     Subd. 3.  [CASE-BY-CASE BASIS.] Coverage under subdivision 
  9.18  2 may be provided on a case-by-case basis if the treatment is 
  9.19  being provided in a phase I clinical trial for any 
  9.20  life-threatening condition other than cancer. 
  9.21     Sec. 7.  [QUALITY OF PATIENT CARE.] 
  9.22     The commissioner of health, in consultation with the 
  9.23  Minnesota Nurses Association, shall develop and submit to the 
  9.24  legislature by February 1, 2001, a plan for the collection of 
  9.25  data on the quality of patient care provided in hospitals, 
  9.26  outpatient surgical centers, and medical clinics.  In developing 
  9.27  the plan, the commissioner shall consider the collection of data 
  9.28  on variables sensitive to both nursing care and medical care, 
  9.29  such as infection rate, medication errors, skin breakdown, and 
  9.30  patient injuries.  The plan must address the release of this 
  9.31  data in a useful form to the public.  
  9.32     Sec. 8.  [EFFECTIVE DATE.] 
  9.33     Sections 3 and 4 are effective January 1, 2001.  Section 5 
  9.34  is effective for all new policies, contracts, or health benefit 
  9.35  plans issued or renewed on or after January 1, 2001.  Section 6 
  9.36  is effective the day following final enactment.