2005 Minnesota Statutes

CHAPTER 62Q. Requirements for health plan companies

     62Q.01 Definitions. 

    Subdivision 1.    Applicability.  For purposes of this 
 chapter, the terms defined in this section have the meanings 
 given. 

    Subd. 2.    Commissioner.  "Commissioner" means the 
 commissioner of health for purposes of regulating health 
 maintenance organizations, and community integrated service 
 networks, or the commissioner of commerce for purposes of 
 regulating all other health plan companies.  For all other 
 purposes, "commissioner" means the commissioner of health. 

    Subd. 2a.    Enrollee.  "Enrollee" means a natural 
 person covered by a health plan and includes an insured, 
 policyholder, subscriber, contract holder, member, covered 
 person, or certificate holder. 

    Subd. 3.    Health plan.  "Health plan" means a health 
 plan as defined in section 62A.011 or a policy, contract, or 
 certificate issued by a community integrated service network. 

    Subd. 4.    Health plan company.  "Health plan company" 
 means: 

    (1) a health carrier as defined under section 62A.011, 
 subdivision 2; or 

    (2) a community integrated service network as defined under 
 section 62N.02, subdivision 4a. 

    Subd. 4a.    High deductible health plans.  "High 
 deductible health plans" means those health coverage plans 
 issued by a health plan company as defined under the provisions 
 of sections 220 and 223 of the Internal Revenue Code of 1986, 
 and implementing regulations. 

    Subd. 5.    Managed care organization.  "Managed care 
 organization" means:  (1) a health maintenance organization 
 operating under chapter 62D; (2) a community integrated service 
 network as defined under section 62N.02, subdivision 4a; or (3) 
 an insurance company licensed under chapter 60A, nonprofit 
 health service plan corporation operating under chapter 62C, 
 fraternal benefit society operating under chapter 64B, or any 
 other health plan company, to the extent that it covers health 
 care services delivered to Minnesota residents through a 
 preferred provider organization or a network of selected 
 providers.  

    Subd. 6.    Medicare-related coverage.  
 "Medicare-related coverage" means a policy, contract, or 
 certificate issued as a supplement to Medicare, regulated under 
 sections 62A.31 to 62A.44, including Medicare select coverage; 
 policies, contracts, or certificates that supplement Medicare 
 issued by health maintenance organizations; or policies, 
 contracts, or certificates governed by sections 1833 (known as 
 "cost" or "HCPP" contracts), 1851 to 1859 (Medicare Advantage), 
 1860D (Medicare Part D), or 1876 (known as "TEFRA" or "risk" 
 contracts) of the federal Social Security Act, United States 
 Code, title 42, section 1395, et seq., as amended; or Section 
 4001 of the Balanced Budget Act of 1997 (BBA)(Public Law 
 105-33), Sections 1851 to 1859 of the Social Security Act 
 establishing Part C of the Medicare program, known as the 
 "Medicare Advantage program." 

    HIST: 1994 c 625 art 2 s 14; 1995 c 234 art 2 s 2-6; art 3 s 
 5; 1997 c 225 art 2 s 37-39,62; 1998 c 254 art 1 s 15; 2001 c 
 215 s 26; 2004 c 268 s 7; 2005 c 17 art 3 s 2 

     62Q.02 Applicability of chapter. 

    (a) This chapter applies only to health plans, as defined 
 in section 62Q.01, and not to other types of insurance issued or 
 renewed by health plan companies, unless otherwise specified. 

    (b) This chapter applies to a health plan company only with 
 respect to health plans, as defined in section 62Q.01, issued or 
 renewed by the health plan company, unless otherwise specified. 

    (c) If a health plan company issues or renews health plans 
 in other states, this chapter applies only to health plans 
 issued or renewed in this state for Minnesota residents, or to 
 cover a resident of the state, unless otherwise specified. 

    HIST: 1995 c 234 art 2 s 7 

     62Q.021 Federal act; compliance required. 

    Each health plan company shall comply with the federal 
 Health Insurance Portability and Accountability Act of 1996, 
 including any federal regulations adopted under that act, to the 
 extent that it imposes a requirement that applies in this state 
 and that is not also required by the laws of this state.  This 
 section does not require compliance with any provision of the 
 federal act prior to the effective date provided for that 
 provision in the federal act.  The commissioner shall enforce 
 this section. 

    HIST: 1997 c 175 art 4 s 2 

     62Q.025 Product approvals. 

    Subdivision 1.    Qualified plan.  A high deductible 
 health plan shall be deemed a qualified plan under sections 
 62E.06 and 62E.12.  The plan must meet all other requirements of 
 state law except those that are inconsistent with a high 
 deductible health plan as defined in sections 220 and 223 of the 
 Internal Revenue Code and supporting regulations. 

    Subd. 2.    Authorization.  Notwithstanding any other 
 law of this state, any health plan company defined in section 
 62Q.01, subdivision 4, is permitted to offer high deductible 
 health plans. 

    HIST: 2004 c 268 s 8 

     62Q.03 Process for defining, developing, and 
  implementing a risk adjustment system. 

    Subdivision 1.    Purpose.  The purpose of risk 
 adjustment is to reduce the effects of risk selection on health 
 insurance premiums by making monetary transfers from health plan 
 companies that insure lower risk populations to health plan 
 companies that insure higher risk populations.  Risk adjustment 
 is needed to:  achieve a more equitable, efficient system of 
 health care financing; remove current disincentives in the 
 health care system to insure and provide adequate access for 
 high risk and special needs populations; promote fair 
 competition among health plan companies on the basis of their 
 ability to efficiently and effectively provide services rather 
 than on the risk status of those in a given insurance pool; and 
 help maintain the viability of health plan companies, by 
 protecting them from the financial effects of enrolling a 
 disproportionate number of high risk individuals.  It is the 
 commitment of the state to develop and implement a risk 
 adjustment system.  The risk adjustment system shall:  

    (1) possess a reasonable level of accuracy and 
 administrative feasibility, be adaptable to changes as methods 
 improve, incorporate safeguards against fraud and manipulation, 
 and shall neither reward inefficiency nor penalize for 
 verifiable improvements in health status; 

    (2) require participation by all health plan companies 
 providing coverage in the individual, small group, and Medicare 
 supplement markets; 

    (3) address unequal distribution of risk between health 
 plan companies, but shall not address the financing of public 
 programs or subsidies for low-income people; and 

    (4) be developed and implemented by the Risk Adjustment 
 Association with joint oversight by the commissioners of health 
 and commerce. 

    Subd. 2. Repealed, 1995 c 234 art 2 s 36 

    Subd. 3. Repealed, 1995 c 234 art 2 s 36 

    Subd. 4. Repealed, 1995 c 234 art 2 s 36 

    Subd. 5. Repealed, 1995 c 234 art 2 s 36 

    Subd. 5a.    Public programs.  (a) A separate risk 
 adjustment system must be developed for state-run public 
 programs, including medical assistance, general assistance 
 medical care, and MinnesotaCare.  The system must be developed 
 in accordance with the general risk adjustment methodologies 
 described in this section, must include factors in addition to 
 age and sex adjustment, and may include additional demographic 
 factors, different targeted conditions, and/or different payment 
 amounts for conditions.  The risk adjustment system for public 
 programs must attempt to reflect the special needs related to 
 poverty, cultural, or language barriers and other needs of the 
 public program population. 

    (b) The commissioner of human services shall phase in risk 
 adjustment according to the following schedule: 

    (1) for the first contract year, no more than ten percent 
 of reimbursements shall be risk adjusted; and 

    (2) for the second contract year, no more than 30 percent 
 of reimbursements shall be risk adjusted. 

    Subd. 5b.    Medicare supplement market.  A risk 
 adjustment system may be developed for the Medicare supplement 
 market.  The Medicare supplement risk adjustment system may 
 include a demographic component and may, but is not required to, 
 include a condition-specific risk adjustment component.  

    Subd. 6.    Creation of Risk Adjustment Association.  
 The Minnesota Risk Adjustment Association is created on July 1, 
 1994, and may operate as a nonprofit unincorporated association, 
 but is authorized to incorporate under chapter 317A. 

    The provisions of this chapter govern if the provisions of 
 chapter 317A conflict with this chapter.  The association may 
 operate under the approved plan of operation and shall be 
 governed in accordance with this chapter and may operate in 
 accordance with chapter 317A.  If the association incorporates 
 as a nonprofit corporation under chapter 317A, the filing of the 
 plan of operation meets the requirements of filing articles of 
 incorporation. 

    The association, its transactions, and all property owned 
 by it are exempt from taxation under the laws of this state or 
 any of its subdivisions, including, but not limited to, income 
 tax, sales tax, use tax, and property tax.  The association may 
 seek exemption from payment of all fees and taxes levied by the 
 federal government.  Except as otherwise provided in this 
 chapter, the association is not subject to the provisions of 
 chapters 14, 60A, and 62A.  The association is not a public 
 employer and is not subject to the provisions of chapters 179A 
 and 353.  The board of directors and health carriers who are 
 members of the association are exempt from sections 325D.49 to 
 325D.66 in the performance of their duties as directors and 
 members of the association.  The Risk Adjustment Association is 
 subject to the Open Meeting Law. 

    Subd. 7.    Purpose of association.  The association is 
 established to develop and implement a private sector risk 
 adjustment system.  

    Subject to state oversight set forth in subdivision 10, the 
 association shall:  

    (1) develop and implement comprehensive risk adjustment 
 systems for individual, small group, and Medicare supplement 
 markets consistent with the provisions of this chapter; 

    (2) submit a plan for the development of the risk 
 adjustment system which identifies appropriate implementation 
 dates consistent with the rating and underwriting restrictions 
 of each market, recommends whether transfers attributable to 
 risk adjustment should be required between the individual and 
 small group markets, and makes other appropriate recommendations 
 to the commissioners of health and commerce by November 5, 1995; 

    (3) develop a combination of a demographic risk adjustment 
 system and payments for targeted conditions; 

    (4) test an ambulatory care groups (ACGs) and diagnostic 
 cost groups (DCGs) system, and recommend whether such a 
 methodology should be adopted; 

    (5) fund the development and testing of the risk adjustment 
 system; 

    (6) recommend market conduct guidelines; and 

    (7) develop a plan for assessing members for the costs of 
 administering the risk adjustment system. 

    Subd. 8.    Governance.  The association shall be 
 governed according to the plan of operation as established in 
 subdivision 8a. 

    Subd. 8a.    Plan of operation.  The board shall submit 
 a proposed plan of operation by August 15, 1995, to the 
 commissioners of health and commerce for review.  The 
 commissioners of health and commerce shall have the authority to 
 approve or reject the plan of operation. 

    Amendments to the plan of operation may be made by the 
 commissioners or by the directors of the association, subject to 
 the approval of the commissioners. 

    Subd. 9.    Data collection and data privacy.  The 
 association members shall not have access to unaggregated data 
 on individuals or health plan companies.  The association shall 
 develop, as a part of the plan of operation, procedures for 
 ensuring that data is collected by an appropriate entity.  The 
 commissioners of health and commerce shall have the authority to 
 audit and examine data collected by the association for the 
 purposes of the development and implementation of the risk 
 adjustment system.  Data on individuals obtained for the 
 purposes of risk adjustment development, testing, and operation 
 are designated as private data.  Data not on individuals which 
 is obtained for the purposes of development, testing, and 
 operation of risk adjustment are designated as nonpublic data, 
 except that the proposed and approved plan of operation, the 
 risk adjustment methodologies examined, the plan for testing, 
 the plan of the risk adjustment system, minutes of meetings, and 
 other general operating information are classified as public 
 data.  Nothing in this section is intended to prohibit the 
 preparation of summary data under section 13.05, subdivision 7.  
 The association, state agencies, and any contractors having 
 access to this data shall maintain it in accordance with this 
 classification.  The commissioners of health and human services 
 have the authority to collect data from health plan companies as 
 needed for the purpose of developing a risk adjustment mechanism 
 for public programs. 

    Subd. 10.    State oversight of risk adjustment 
 activities.  The association's activities shall be supervised 
 by the commissioners of health and commerce.  The commissioners 
 shall provide specific oversight functions during the 
 development and implementation phases of the risk adjustment 
 system as follows: 

    (1) the commissioners shall approve or reject the 
 association's plan for testing risk adjustment methods, the 
 methods to be used, and any changes to those methods; 

    (2) the commissioners must have the right to attend and 
 participate in all meetings of the association and its work 
 groups or committees, except for meetings involving privileged 
 communication between the association and its counsel as 
 permitted under section 13D.05, subdivision 3, paragraph (b); 

    (3) the commissioners shall approve any consultants or 
 administrators used by the association; 

    (4) the commissioners shall approve or reject the 
 association's plan of operation; and 

    (5) the commissioners shall approve or reject the plan for 
 the risk adjustment system described in subdivision 7, clause 
 (2). 

    If the commissioners reject any of the plans identified in 
 clauses (1), (4), and (5), the directors shall submit for review 
 an appropriate revised plan within 30 days. 

    Subd. 11. Repealed, 1995 c 234 art 2 s 36 

    Subd. 12.    Participation by all health plan companies. 
  Upon its implementation, all health plan companies, as a 
 condition of licensure, must participate in the risk adjustment 
 system to be implemented under this section. 

    HIST: 1994 c 625 art 2 s 15; 1995 c 234 art 2 s 8-17; 1996 c 
 440 art 1 s 33; 1996 c 451 art 4 s 2; 1997 c 192 s 18; 1997 c 
 225 art 2 s 40; 1998 c 254 art 1 s 16; 1999 c 245 art 2 s 12; 
 2001 c 161 s 15 

  62Q.07 Repealed, 2001 c 170 s 11 

     62Q.075 Local public accountability and collaboration 
  plan. 

    Subdivision 1. Repealed by amendment, 2001 c 171 s 1 

    Subd. 2.    Requirement.  Beginning October 31, 2004, 
 all health maintenance organizations shall file a plan every 
 four years with the commissioner of health describing the 
 actions the health maintenance organization intends to take to 
 contribute to achieving one or more high priority public health 
 goals.  This plan must be jointly developed in collaboration 
 with the local public health units, and other community 
 organizations providing health services within the same service 
 area as the health maintenance organization.  Local government 
 units with responsibilities and authority defined under chapter 
 145A may designate individuals to participate in the 
 collaborative planning with the health maintenance organization 
 to provide expertise and represent community needs and goals as 
 identified under chapter 145A.  Every other year, beginning 
 October 31, 2002, all health maintenance organizations shall 
 file reports updating progress on the four-year collaboration 
 plan. 

    Subd. 3.    Contents.  The plan must address the 
 following: 

    (1) specific measurement strategies and a description of 
 any activities which contribute to one or more high priority 
 public health goals; 

    (2) description of the process by which the health 
 maintenance organization will coordinate its activities with the 
 community health boards, and other relevant community 
 organizations servicing the same area; 

    (3) documentation indicating that local public health units 
 and local government unit designees were involved in the 
 development of the plan; and 

    (4) documentation of compliance with the plan filed 
 previously, including data on the previously identified progress 
 measures. 

    Subd. 4.    Review.  Upon receipt of the plan, the 
 commissioner of health shall provide a copy to the local 
 community health boards, and other relevant community 
 organizations within the health maintenance organization's 
 service area.  After reviewing the plan, these community groups 
 may submit written comments on the plan to the commissioner of 
 health and may advise the commissioner of the health maintenance 
 organization's effectiveness in assisting to achieve high 
 priority public health goals.  The plan may be reviewed by the 
 county boards, or city councils acting as a local board of 
 health in accordance with chapter 145A, within the health 
 maintenance organization's service area to determine whether the 
 plan is consistent with the goals and objectives of the plans 
 required under chapter 145A and whether the plan meets the needs 
 of the community.  The county board, or applicable city council, 
 may also review and make recommendations on the availability and 
 accessibility of services provided by the health maintenance 
 organization.  The county board, or applicable city council, may 
 submit written comments to the commissioner of health, and may 
 advise the commissioner of the health maintenance organization's 
 effectiveness in assisting to meet the needs and goals as 
 defined under the responsibilities of chapter 145A.  Copies of 
 these written comments must be provided to the health 
 maintenance organization.  The plan and any comments submitted 
 must be filed with the information clearinghouse to be 
 distributed to the public. 

    HIST: 1994 c 625 art 7 s 1; 1995 c 234 art 8 s 17; 1996 c 451 
 art 4 s 3; 1997 c 225 art 2 s 62; 1999 c 245 art 2 s 13; 2001 c 
 171 s 1; 2005 c 98 art 3 s 24 

  62Q.09 Expired 

  62Q.095 Repealed, 2005 c 77 s 8 

     62Q.096 Credentialing of providers. 

    If a health plan company has initially credentialed, as 
 providers in its provider network, individual providers employed 
 by or under contract with an entity that: 

    (1) is authorized to bill under section 256B.0625, 
 subdivision 5; 

    (2) meets the requirements of Minnesota Rules, parts 
 9520.0750 to 9520.0870; 

    (3) is designated an essential community provider under 
 section 62Q.19; and 

    (4) is under contract with the health plan company to 
 provide mental health services, the health plan company must 
 continue to credential at least the same number of providers 
 from that entity, as long as those providers meet the health 
 plan company's credentialing standards.  

 A health plan company shall not refuse to credential these 
 providers on the grounds that their provider network has a 
 sufficient number of providers of that type. 

    HIST: 1998 c 407 art 8 s 4 

     62Q.10 Nondiscrimination. 

    If a health plan company, with the exception of a community 
 integrated service network or an indemnity insurer licensed 
 under chapter 60A who does not offer a product through a 
 preferred provider network, offers coverage of a health care 
 service as part of its plan, it may not deny provider network 
 status to a qualified health care provider type who meets the 
 credentialing requirements of the health plan company solely 
 because the provider is an allied independent health care 
 provider as defined in section 62Q.095. 

    HIST: 1994 c 625 art 1 s 18; art 2 s 18 

  62Q.105 Repealed, 1999 c 239 s 43 

     62Q.1055 Chemical dependency. 

    All health plan companies shall use the assessment criteria 
 in Minnesota Rules, parts 9530.6600 to 9530.6660, when assessing 
 and placing enrollees for chemical dependency treatment. 

    HIST: 1995 c 234 art 2 s 22 

     62Q.106 Dispute resolution by commissioner. 

    A complainant may at any time submit a complaint to the 
 appropriate commissioner to investigate.  After investigating a 
 complaint, or reviewing a company's decision, the appropriate 
 commissioner may order a remedy as authorized under chapter 45, 
 60A, or 62D.  

    HIST: 1995 c 234 art 2 s 23; 1997 c 225 art 2 s 41; 1999 c 239 
 s 32 

     62Q.107 Prohibited provision; judicial review. 

    Beginning January 1, 1999, no health plan, including the 
 coverages described in section 62A.011, subdivision 3, clauses 
 (7) and (10), may specify a standard of review upon which a 
 court may review denial of a claim or of any other decision made 
 by a health plan company with respect to an enrollee.  This 
 section prohibits limiting court review to a determination of 
 whether the health plan company's decision is arbitrary and 
 capricious, an abuse of discretion, or any other standard less 
 favorable to the enrollee than a preponderance of the evidence.  

    HIST: 1998 c 407 art 2 s 21 

  62Q.11 Repealed, 1999 c 239 s 43 

     62Q.12 Denial of access. 

    No health plan company may deny access to a covered health 
 care service unless the denial is made by, or under the 
 direction of, or subject to the review of a health care 
 professional licensed to provide the service in question. 

    HIST: 1994 c 625 art 2 s 20 

     62Q.121 Licensure of medical directors. 

    (a) No health plan company may employ a person as a medical 
 director unless the person is licensed as a physician in this 
 state.  This section does not apply to a health plan company 
 that is assessed less than three percent of the total amount 
 assessed by the Minnesota Comprehensive Health Association. 

    (b) For purposes of this section, "medical director" means 
 a physician employed by a health plan company who has direct 
 decision-making authority, based upon medical training and 
 knowledge, regarding the health plan company's medical 
 protocols, medical policies, or coverage of treatment of a 
 particular enrollee, regardless of the physician's title. 

    (c) This section applies only to medical directors who make 
 recommendations or decisions that involve or affect enrollees 
 who live in this state. 

    (d) Each health plan company that is subject to this 
 section shall provide the commissioner with the names and 
 licensure information of its medical directors and shall provide 
 updates no later than 30 days after any changes. 

    HIST: 1Sp2001 c 9 art 16 s 6; 2002 c 379 art 1 s 113 

     62Q.135 Contracting for chemical dependency services. 

    No health plan company shall contract with a chemical 
 dependency treatment program, unless the program participates in 
 the chemical dependency treatment accountability plan 
 established by the commissioner of human services.  The 
 commissioner of human services shall make data on chemical 
 dependency services and outcomes collected through this program 
 available to health plan companies. 

    HIST: 1994 c 625 art 2 s 21 

     62Q.137 Coverage for chemical dependency treatment 
  provided by the Department of Corrections. 

    (a) Any health plan that provides coverage for chemical 
 dependency treatment must cover chemical dependency treatment 
 provided to an enrollee by the Department of Corrections while 
 the enrollee is committed to the custody of the commissioner of 
 corrections following a conviction for a first-degree driving 
 while impaired offense under section 169A.24 if:  (1) a court of 
 competent jurisdiction makes a preliminary determination based 
 on a chemical use assessment conducted under section 169A.70 
 that treatment may be appropriate and includes this 
 determination as part of the sentencing order; and (2) the 
 Department of Corrections makes a determination based on a 
 chemical assessment conducted while the individual is in the 
 custody of the department that treatment is appropriate.  
 Treatment provided by the Department of Corrections that meets 
 the requirements of this section shall not be subject to a 
 separate medical necessity determination under the health plan 
 company's utilization review procedures.  

    (b) The health plan company must be given a copy of the 
 court's preliminary determination and supporting documents and 
 the assessment conducted by the Department of Corrections.  

    (c) Payment rates for treatment provided by the Department 
 of Corrections shall not exceed the lowest rate for outpatient 
 chemical dependency treatment paid by the health plan company to 
 a participating provider of the health plan company.  

    (d) For purposes of this section, chemical dependency 
 treatment means all covered services that are intended to treat 
 chemical dependency and that are covered by the enrollee's 
 health plan or by law. 

    HIST: 1Sp2001 c 9 art 19 s 1; 2002 c 379 art 1 s 113 

     62Q.14 Restrictions on enrollee services. 

    No health plan company may restrict the choice of an 
 enrollee as to where the enrollee receives services related to: 

    (1) the voluntary planning of the conception and bearing of 
 children, provided that this clause does not refer to abortion 
 services; 

    (2) the diagnosis of infertility; 

    (3) the testing and treatment of a sexually transmitted 
 disease; and 

    (4) the testing for AIDS or other HIV-related conditions. 

    HIST: 1994 c 625 art 2 s 22 

     62Q.145 Abortion and scope of practice. 

    Health plan company policies related to scope of practice 
 for allied independent health providers as defined in section 
 62Q.095, subdivision 5, midlevel practitioners as defined in 
 section 144.1501, subdivision 1, and other nonphysician health 
 care professionals must comply with the requirements governing 
 the performance of abortions in section 145.412, subdivision 1. 

    HIST: 1995 c 234 art 2 s 25; 1997 c 183 art 2 s 20; 1Sp2003 c 
 14 art 7 s 88 

     62Q.16 Midmonth termination prohibited. 

    The termination of a person's coverage under any health 
 plan as defined in section 62A.011, subdivision 3, with the 
 exception of individual health plans, issued or renewed on or 
 after January 1, 1995, must provide coverage until the end of 
 the month in which coverage was terminated. 

    HIST: 1994 c 625 art 2 s 23 

     62Q.165 Universal coverage. 

    Subdivision 1.    Definition.  It is the commitment of 
 the state to achieve universal health coverage for all 
 Minnesotans.  Universal coverage is achieved when:  

    (1) every Minnesotan has access to a full range of quality 
 health care services; 

    (2) every Minnesotan is able to obtain affordable health 
 coverage which pays for the full range of services, including 
 preventive and primary care; and 

    (3) every Minnesotan pays into the health care system 
 according to that person's ability.  

    Subd. 2.    Goal.  It is the goal of the state to make 
 continuous progress toward reducing the number of Minnesotans 
 who do not have health coverage so that by January 1, 2000, 
 fewer than four percent of the state's population will be 
 without health coverage.  The goal will be achieved by improving 
 access to private health coverage through insurance reforms and 
 market reforms, by making health coverage more affordable for 
 low-income Minnesotans through purchasing pools and state 
 subsidies, and by reducing the cost of health coverage through 
 cost containment programs and methods of ensuring that all 
 Minnesotans are paying into the system according to their 
 ability. 

    Subd. 3. Repealed, 1997 c 225 art 2 s 63 

    HIST: 1994 c 625 art 6 s 1; 1995 c 234 art 4 s 1 

     62Q.17 Voluntary purchasing pools. 

    Subdivision 1.    Permission to form.  Notwithstanding 
 section 62A.10, employers, groups, and individuals may 
 voluntarily form purchasing pools, solely for the purpose of 
 negotiating and purchasing health plan coverage from health plan 
 companies for members of the pool. 

    Subd. 2.    Common factors.  All participants in a 
 purchasing pool must live within a common geographic region, be 
 employed in a similar occupation, or share some other common 
 factor as approved by the commissioner of commerce.  The 
 membership criteria must not be designed to include 
 disproportionately employers, groups, or individuals likely to 
 have low costs of health coverage, or to exclude 
 disproportionately employers, groups, or individuals likely to 
 have high costs of health coverage.  

    Subd. 3.    Governing structure.  Each pool must have a 
 governing structure controlled by its members.  The governing 
 structure of the pool is responsible for administration of the 
 pool.  The governing structure shall review and evaluate all 
 bids for coverage from health plan companies, shall determine 
 criteria for joining and leaving the pool, and may design 
 incentives for healthy lifestyles and health promotion programs. 
 The governing structure may design uniform entrance standards 
 for all employers, except small employers as defined under 
 section 62L.02.  Small employers must be permitted to enter any 
 pool if the small employer meets the pool's membership 
 requirements.  Pools must provide as much choice in health plans 
 to members as is financially possible.  The governing structure 
 may charge all members a fee for administrative purposes. 

    Subd. 4.    Enrollment.  Pools must have an annual open 
 enrollment period of not less than 15 days, during which all 
 individuals or groups that qualify for membership may enter the 
 pool without any preexisting condition limitations or exclusions 
 or exclusionary riders, except those permitted under chapter 62L 
 for groups or section 62A.65 for individuals.  Pools must reach 
 and maintain an enrolled population of at least 1,000 members 
 within six months of formation.  If a pool fails to reach or 
 maintain the minimum enrollment, all coverage subsequently 
 purchased through the purchasing pool must be regulated through 
 existing applicable laws and forego all advantages under this 
 section. 

    Subd. 5.    Members.  The governing structure of the 
 pool shall set a minimum time period for membership.  Members 
 must stay in the purchasing pool for the entire minimum period 
 to avoid paying a penalty.  Penalties for early withdrawal from 
 the purchasing pool shall be established by the governing 
 structure. 

    Subd. 6.    Employer-based purchasing pools.  
 Employer-based purchasing pools must, with respect to small 
 employers as defined in section 62L.02, meet all the 
 requirements of chapter 62L.  The experience of the pool must be 
 pooled and the rates blended across all groups.  Pools may 
 decide to create tiers within the pool, based on experience of 
 group members.  These tiers must be designed within the 
 requirements of section 62L.08.  The governing structure may 
 establish criteria limiting movement between tiers.  Tiers must 
 be phased out within two years of the pool's creation. 

    Subd. 7.    Individual members.  Purchasing pools that 
 contain individual members must meet all of the underwriting and 
 rate restrictions found in the individual health plan market. 

    Subd. 8.    Reports.  Prior to the initial effective 
 date of coverage, and annually on July 1 thereafter, each pool 
 shall file a report with the information clearinghouse and the 
 commissioner of commerce.  The information clearinghouse must 
 use the report to promote the purchasing pools.  The annual 
 report must contain the following information: 

    (1) the number of lives in the pool; 

    (2) the geographic area the pool intends to cover; 

    (3) the number of health plans offered; 

    (4) a description of the benefits under each plan; 

    (5) a description of the premium structure, including any 
 co-payments or deductibles, of each plan offered; 

    (6) evidence of compliance with chapter 62L; 

    (7) a sample of marketing information, including a phone 
 number where the pool may be contacted; and 

    (8) a list of all administrative fees charged. 

    Subd. 9.    Enforcement.  Purchasing pools must register 
 prior to offering coverage, and annually on July 1 thereafter, 
 with the commissioner of commerce on a form prescribed by the 
 commissioner.  The commissioner of commerce shall enforce this 
 section and all other state laws with respect to purchasing 
 pools, and has for that purpose all general rulemaking and 
 enforcement powers otherwise available to the commissioner of 
 commerce.  The commissioner may charge an annual registration 
 fee sufficient to meet the costs of the commissioner's duties 
 under this section. 

    HIST: 1994 c 625 art 6 s 2; 1995 c 234 art 7 s 24-26 

     62Q.18 Portability of coverage. 

    Subdivision 1.    Definition.  For purposes of this 
 section, 

    (1) "continuous coverage" has the meaning given in section 
 62L.02, subdivision 9; 

    (2) "guaranteed issue" means: 

    (i) for individual health plans, that a health plan company 
 shall not decline an application by an individual for any 
 individual health plan offered by that health plan company, 
 including coverage for a dependent of the individual to whom the 
 health plan has been or would be issued; and 

    (ii) for group health plans, that a health plan company 
 shall not decline an application by a group for any group health 
 plan offered by that health plan company and shall not decline 
 to cover under the group health plan any person eligible for 
 coverage under the group's eligibility requirements, including 
 persons who become eligible after initial issuance of the group 
 health plan; 

    (3) "large employer" means an entity that would be a small 
 employer, as defined in section 62L.02, subdivision 26, except 
 that the entity has more than 50 current employees, based upon 
 the method provided in that subdivision for determining the 
 number of current employees; 

    (4) "preexisting condition" has the meaning given in 
 section 62L.02, subdivision 23; and 

    (5) "qualifying coverage" has the meaning given in section 
 62L.02, subdivision 24. 

    Subd. 2. Repealed, 1995 c 234 art 4 s 4 

    Subd. 3. Repealed, 1995 c 234 art 4 s 4 

    Subd. 4. Repealed, 1995 c 234 art 4 s 4 

    Subd. 5. Repealed, 1995 c 234 art 4 s 4 

    Subd. 6. Repealed, 1995 c 234 art 4 s 4 

    Subd. 7.    Portability of coverage.  Effective July 1, 
 1994, no health plan company shall offer, sell, issue, or renew 
 any group health plan that does not, with respect to individuals 
 who maintain continuous coverage and who qualify under the 
 group's eligibility requirements: 

    (1) make coverage available on a guaranteed issue basis; 

    (2) give full credit for previous continuous coverage 
 against any applicable preexisting condition limitation or 
 preexisting condition exclusion; and 

    (3) with respect to a group health plan offered, sold, 
 issued, or renewed to a large employer, impose preexisting 
 condition limitations or preexisting condition exclusions except 
 to the extent that would be permitted under chapter 62L if the 
 group sponsor were a small employer as defined in section 
 62L.02, subdivision 26. 

    To the extent that this subdivision conflicts with chapter 
 62L, chapter 62L governs, regardless of whether the group 
 sponsor is a small employer as defined in section 62L.02, except 
 that for group health plans issued to groups that are not small 
 employers, this subdivision's requirement that the individual 
 have maintained continuous coverage applies.  An individual who 
 has maintained continuous coverage, but would be considered a 
 late entrant under chapter 62L, may be treated as a late entrant 
 in the same manner under this subdivision as permitted under 
 chapter 62L.  

    Subd. 8. Repealed, 1995 c 234 art 4 s 4 

    Subd. 9. Repealed, 1995 c 234 art 4 s 4 

    HIST: 1994 c 625 art 6 s 3; art 8 s 72; 1995 c 96 s 2; 1995 c 
 234 art 4 s 2; 1997 c 175 art 3 s 1,2; 1997 c 225 art 2 s 63 

     62Q.181 Written certification of coverage. 

    A health plan company shall provide the written 
 certifications of coverage required under United States Code, 
 title 42, sections 300gg(e) and 300gg-43.  This section applies 
 only to coverage that is subject to regulation under state law 
 and only to the extent that the certification of coverage is 
 required under federal law.  The commissioner shall enforce this 
 section. 

    HIST: 1997 c 175 art 4 s 3 

     62Q.185 Guaranteed renewability; large employer group 
  health coverage. 

    (a) No health plan company, as defined in section 62Q.01, 
 subdivision 4, shall refuse to renew a health benefit plan, as 
 defined in section 62L.02, subdivision 15, but issued to a large 
 employer, as defined in section 62Q.18, subdivision 1. 

    (b) This section does not require renewal if: 

    (1) the large employer has failed to pay premiums or 
 contributions as required under the terms of the health benefit 
 plan, or the health plan company has not received timely premium 
 payments unless the late payments were received within a grace 
 period provided under state law; 

    (2) the large employer has performed an act or practice 
 that constitutes fraud or misrepresentation of material fact 
 under the terms of the health benefit plan; 

    (3) the large employer has failed to comply with a material 
 plan provision relating to employer contribution or group 
 participation rules not prohibited by state law; 

    (4) the health plan company is ceasing to offer coverage in 
 the large employer market in this state in compliance with 
 United States Code, title 42, section 300gg-12(c), and 
 applicable state law; 

    (5) in the case of a health maintenance organization, there 
 is no longer any enrollee in the large employer's health benefit 
 plan who lives, resides, or works in the approved service area; 
 or 

    (6) in the case of a health benefit plan made available to 
 large employers only through one or more bona fide associations, 
 the membership of the large employer in the association ceases, 
 but only if such coverage is terminated uniformly without regard 
 to any health-related factor relating to any covered individual. 

    (c) This section does not prohibit a health plan company 
 from modifying the premium rate or from modifying the coverage 
 for purposes of renewal. 

    (d) This section does not require renewal of the coverage 
 of individual enrollees under the health benefit plan if the 
 individual enrollee has performed an act or practice that 
 constitutes fraud or misrepresentation of material fact under 
 the terms of the health benefit plan. 

    HIST: 1997 c 175 art 3 s 3; 1999 c 177 s 57 

     62Q.19 Essential community providers. 

    Subdivision 1.    Designation.  (a) The commissioner 
 shall designate essential community providers.  The criteria for 
 essential community provider designation shall be the following: 

    (1) a demonstrated ability to integrate applicable 
 supportive and stabilizing services with medical care for 
 uninsured persons and high-risk and special needs populations, 
 underserved, and other special needs populations; and 

    (2) a commitment to serve low-income and underserved 
 populations by meeting the following requirements: 

    (i) has nonprofit status in accordance with chapter 317A; 

    (ii) has tax exempt status in accordance with the Internal 
 Revenue Service Code, section 501(c)(3); 

    (iii) charges for services on a sliding fee schedule based 
 on current poverty income guidelines; and 

    (iv) does not restrict access or services because of a 
 client's financial limitation; 

    (3) status as a local government unit as defined in section 
 62D.02, subdivision 11, a hospital district created or 
 reorganized under sections 447.31 to 447.37, an Indian tribal 
 government, an Indian health service unit, or a community health 
 board as defined in chapter 145A; 

    (4) a former state hospital that specializes in the 
 treatment of cerebral palsy, spina bifida, epilepsy, closed head 
 injuries, specialized orthopedic problems, and other disabling 
 conditions; or 

    (5) a sole community hospital.  For these rural hospitals, 
 the essential community provider designation applies to all 
 health services provided, including both inpatient and 
 outpatient services.  For purposes of this section, "sole 
 community hospital" means a rural hospital that: 

    (i) is eligible to be classified as a sole community 
 hospital according to Code of Federal Regulations, title 42, 
 section 412.92, or is located in a community with a population 
 of less than 5,000 and located more than 25 miles from a like 
 hospital currently providing acute short-term services; 

    (ii) has experienced net operating income losses in two of 
 the previous three most recent consecutive hospital fiscal years 
 for which audited financial information is available; and 

    (iii) consists of 40 or fewer licensed beds. 

    (b) Prior to designation, the commissioner shall publish 
 the names of all applicants in the State Register.  The public 
 shall have 30 days from the date of publication to submit 
 written comments to the commissioner on the application.  No 
 designation shall be made by the commissioner until the 30-day 
 period has expired. 

    (c) The commissioner may designate an eligible provider as 
 an essential community provider for all the services offered by 
 that provider or for specific services designated by the 
 commissioner. 

    (d) For the purpose of this subdivision, supportive and 
 stabilizing services include at a minimum, transportation, child 
 care, cultural, and linguistic services where appropriate. 

    Subd. 2.    Application.  (a) Any provider may apply to 
 the commissioner for designation as an essential community 
 provider by submitting an application form developed by the 
 commissioner.  Except as provided in paragraphs (d) and (e), 
 applications must be accepted within two years after the 
 effective date of the rules adopted by the commissioner to 
 implement this section. 

    (b) Each application submitted must be accompanied by an 
 application fee in an amount determined by the commissioner.  
 The fee shall be no more than what is needed to cover the 
 administrative costs of processing the application. 

    (c) The name, address, contact person, and the date by 
 which the commissioner's decision is expected to be made shall 
 be classified as public data under section 13.41.  All other 
 information contained in the application form shall be 
 classified as private data under section 13.41 until the 
 application has been approved, approved as modified, or denied 
 by the commissioner.  Once the decision has been made, all 
 information shall be classified as public data unless the 
 applicant designates and the commissioner determines that the 
 information contains trade secret information. 

    (d) The commissioner shall accept an application for 
 designation as an essential community provider until June 30, 
 2004, from one applicant that is a nonprofit community services 
 agency certified as a medical assistance provider that provides 
 mental health, behavioral health, chemical dependency, 
 employment, and health wellness services to the underserved 
 Spanish-speaking Latino families and individuals with locations 
 in Minneapolis and St. Paul. 

    Subd. 2a.    Definition of health plan company.  For 
 purposes of this section, "health plan company" does not include 
 a health plan company as defined in section 62Q.01 with fewer 
 than 50,000 enrollees, all of whose enrollees are covered under 
 medical assistance, general assistance medical care, or 
 MinnesotaCare. 

    Subd. 3.    Health plan company affiliation.  A health 
 plan company must offer a provider contract to any designated 
 essential community provider located within the area served by 
 the health plan company.  A health plan company shall not 
 restrict enrollee access to services designated to be provided 
 by the essential community provider for the population that the 
 essential community provider is certified to serve.  A health 
 plan company may also make other providers available for these 
 services.  A health plan company may require an essential 
 community provider to meet all data requirements, utilization 
 review, and quality assurance requirements on the same basis as 
 other health plan providers.  

    Subd. 4.    Essential community provider responsibilities. 
  Essential community providers must agree to serve enrollees 
 of all health plan companies operating in the area in which the 
 essential community provider is located. 

    Subd. 5.    Contract payment rates.  An essential 
 community provider and a health plan company may negotiate the 
 payment rate for covered services provided by the essential 
 community provider.  This rate must be at least the same rate 
 per unit of service as is paid to other health plan providers 
 for the same or similar services. 

    Subd. 5a.    Cooperation.  Each health plan company and 
 essential community provider shall cooperate to facilitate the 
 use of the essential community provider by the high risk and 
 special needs populations.  This includes cooperation on the 
 submission and processing of claims, sharing of all pertinent 
 records and data, including performance indicators and specific 
 outcomes data, and the use of all dispute resolution methods. 

    Subd. 5b.    Enforcement.  For any violation of this 
 section or any rule applicable to an essential community 
 provider, the commissioner may suspend, modify, or revoke an 
 essential community provider designation.  The commissioner may 
 also use the enforcement authority specified in section 62D.17. 

    Subd. 6.    Termination or renewal of designation; 
 commissioner review.  The designation as an essential 
 community provider shall be valid for a five-year period from 
 the date of designation.  Five years after the designation of 
 essential community provider is granted to a provider, the 
 commissioner shall review the need for and appropriateness of 
 continuing the designation for that provider.  The commissioner 
 may require a provider whose designation is to be reviewed to 
 submit an application to the commissioner for renewal of the 
 designation and may require an application fee to be submitted 
 with the application to cover the administrative costs of 
 processing the application.  Based on that review, the 
 commissioner may renew a provider's essential community provider 
 designation for an additional five-year period or terminate the 
 designation.  Once the designation terminates, the former 
 essential community provider has no rights or privileges beyond 
 those of any other health care provider.  

    Subd. 7.    Rulemaking.  By January 1, 1996, the 
 commissioner shall adopt rules for establishing essential 
 community providers and for governing their relationship with 
 health plan companies.  The commissioner shall also identify and 
 address any conflict of interest issues regarding essential 
 community provider designation for local governments.  The rules 
 shall require health plan companies to comply with all 
 provisions of section 62Q.14 with respect to enrollee use of 
 essential community providers. 

    HIST: 1994 c 625 art 4 s 6; 1995 c 234 art 2 s 26; 1996 c 451 
 art 2 s 1,2; 1997 c 225 art 2 s 42; 1999 c 239 s 33; 2000 c 340 
 s 1,2; 2001 c 170 s 3; 2003 c 100 s 1; 1Sp2003 c 14 art 7 s 
 22,23; 2004 c 279 art 9 s 1 

  62Q.21 Repealed, 1995 c 234 art 2 s 36 

     62Q.22 Health care services prepaid option. 

    Subdivision 1.    Scope.  A community health clinic that 
 is designated as an essential community provider under section 
 62Q.19 and is associated with a hospital, a governmental unit, 
 or the University of Minnesota may offer to individuals and 
 families the option of purchasing basic health care services on 
 a fixed prepaid basis without satisfying the requirements of 
 chapter 60A, 62A, 62C, or 62D, or any other law or rule that 
 applies to entities licensed under those chapters.  

    Subd. 2.    Registration.  A community health clinic 
 that offers a prepaid option under this section must register on 
 an annual basis with the commissioner of health. 

    Subd. 3.    Premiums.  The premiums for a prepaid option 
 offered under this section must be based on a sliding fee 
 schedule based on current poverty income guidelines.  

    Subd. 4.    Health care services.  (a) A prepaid option 
 offered under this section must provide basic health care 
 services including: 

    (1) services for the diagnosis and treatment of injuries, 
 illnesses, or conditions; 

    (2) child health supervision services up to age 18, as 
 defined under section 62A.047; and 

    (3) preventive health services, including: 

    (i) health education; 

    (ii) health supervision, evaluation, and follow-up; 

    (iii) immunization; and 

    (iv) early disease detection. 

    (b) Inpatient hospital services shall not be offered as a 
 part of a community health clinic's prepaid option.  A clinic 
 may associate with a hospital to provide hospital services to an 
 individual or family who is enrolled in the prepaid option so 
 long as these services are not offered as part of the prepaid 
 option. 

    (c) All health care services included by the community 
 health clinic in a prepaid option must be services that are 
 offered within the scope of practice of the clinic by the 
 clinic's professional staff.  

    Subd. 5.    Guaranteed renewability.  A community health 
 clinic shall not refuse to renew a prepaid option, except for 
 nonpayment of premiums, fraud, or misrepresentation, or as 
 permitted under subdivisions 8 and 9, paragraph (b).  

    Subd. 6.    Information to be provided.  (a) A community 
 health clinic must provide an individual or family who purchases 
 a prepaid option a clear and concise written statement that 
 includes the following information: 

    (1) the health care services that the prepaid option 
 covers; 

    (2) any exclusions or limitations on the health care 
 services offered, including any preexisting condition 
 limitations, cost-sharing arrangements, or prior authorization 
 requirements; 

    (3) where the health care services may be obtained; 

    (4) a description of the clinic's method for resolving 
 patient complaints, including a description of how a patient can 
 file a complaint with the Department of Health; and 

    (5) a description of the conditions under which the prepaid 
 option may be canceled or terminated. 

    (b) The commissioner of health must approve a copy of the 
 written statement before the community health clinic may offer 
 the prepaid option described in this section.  

    Subd. 7.    Complaint process.  (a) A community health 
 clinic that offers a prepaid option under this section must 
 establish a complaint resolution process.  As an alternative to 
 establishing its own process, a community health clinic may use 
 the complaint process of another organization.  

    (b) A community health clinic must make reasonable efforts 
 to resolve complaints and to inform complainants in writing of 
 the clinic's decision within 60 days of receiving the complaint. 

    (c) A community health clinic that offers a prepaid option 
 under this section must report all complaints that are not 
 resolved within 60 days to the commissioner of health. 

    Subd. 8.    Public assistance program eligibility.  A 
 community health clinic may require an individual or family 
 enrolled in the clinic's prepaid option to apply for medical 
 assistance, general assistance medical care, or the 
 MinnesotaCare program.  The clinic must assist the individual or 
 family in filing the application for the appropriate public 
 program.  If, upon the request of the clinic, an individual or 
 family refuses to apply for these programs, the clinic may 
 disenroll the individual or family from the prepaid option at 
 any time. 

    Subd. 9.    Limitations on enrollment.  (a) A community 
 health clinic may limit enrollment in its prepaid option.  If 
 enrollment is limited, a waiting list must be established. 

    (b) A community health clinic may deny enrollment in its 
 prepaid option to an individual or family whose gross family 
 income is greater than 275 percent of the federal poverty 
 guidelines. 

    (c) No community health clinic may restrict or deny 
 enrollment in its prepaid option because of an individual's or a 
 family's financial limitations, except as permitted under this 
 subdivision. 

    HIST: 1997 c 194 s 1 

     62Q.23 General services. 

    (a) Health plan companies shall comply with all 
 continuation and conversion of coverage requirements applicable 
 to health maintenance organizations under state or federal law. 

    (b) Health plan companies shall comply with sections 
 62A.047, 62A.27, and any other coverage required under chapter 
 62A of newborn infants, dependent children who do not reside 
 with a covered person, handicapped children and dependents, and 
 adopted children.  A health plan company providing dependent 
 coverage shall comply with section 62A.302. 

    (c) Health plan companies shall comply with the equal 
 access requirements of section 62A.15. 

    HIST: 1994 c 625 art 4 s 8 

  62Q.25 Repealed, 1997 c 225 art 2 s 63 

     62Q.251 Discounted payments. 

    (a) Notwithstanding any other provision of law, a health 
 care provider may provide care to a patient at a discounted 
 payment amount.  

    (b) A health plan company or other insurer must not 
 consider, in determining a provider's usual and customary 
 payment, standard payment, or allowable payment used as a basis 
 for determining the provider's payment by the health plan 
 company or other insurer, the following discounted payment 
 situations: 

    (1) care provided to relatives of the provider; 

    (2) care for which a discount is given for hardship 
 situations; and 

    (3) care for which a discount is given in exchange for cash 
 payment. 

    (c) Nothing in this section shall prohibit a provider from 
 providing charity care for hardship situations in which the care 
 is provided for free. 

    HIST: 2005 c 147 art 11 s 3; 1Sp2005 c 4 art 8 s 3 

  62Q.27 Repealed, 1995 c 234 art 2 s 36 

  62Q.29 Repealed, 1997 c 225 art 2 s 63 

  62Q.30 Repealed, 1999 c 239 s 43 

     62Q.32 Local ombudsperson. 

    County board or community health service agencies may 
 establish an office of ombudsperson to provide a system of 
 consumer advocacy for persons receiving health care services 
 through a health plan company.  The ombudsperson's functions may 
 include, but are not limited to: 

    (a) mediation or advocacy on behalf of a person accessing 
 the complaint and appeal procedures to ensure that necessary 
 medical services are provided by the health plan company; and 

    (b) investigation of the quality of services provided to a 
 person and determine the extent to which quality assurance 
 mechanisms are needed or any other system change may be needed.  
 The commissioner of health shall make recommendations for 
 funding these functions including the amount of funding needed 
 and a plan for distribution.  The commissioner shall submit 
 these recommendations to the Legislative Commission on Health 
 Care Access by January 15, 1996. 

    HIST: 1994 c 625 art 7 s 2; 1995 c 234 art 8 s 18 

     62Q.33 Local government public health functions. 

    Subdivision 1.    Findings.  The legislature finds that 
 the local government public health functions of community 
 assessment, policy development, and assurance of service 
 delivery are essential elements in consumer protection and in 
 achieving the objectives of health care reform in Minnesota.  
 The legislature further finds that the site-based and 
 population-based services provided by state and local health 
 departments are a critical strategy for the long-term 
 containment of health care costs.  The legislature further finds 
 that without adequate resources, the local government public 
 health system will lack the capacity to fulfill these functions 
 in a manner consistent with the needs of a reformed health care 
 delivery system. 

    Subd. 2.    Report on system development.  The 
 commissioner of health, in consultation with the State Community 
 Health Services Advisory Committee and the commissioner of human 
 services, and representatives of local health departments, 
 county government, a municipal government acting as a local 
 board of health, area Indian health services, health care 
 providers, and citizens concerned about public health, shall 
 coordinate the process for defining implementation and financing 
 responsibilities of the local government core public health 
 functions.  The commissioner shall submit recommendations and an 
 initial and final report on local government core public health 
 functions according to the timeline established in subdivision 5.

    Subd. 3.    Core public health functions.  (a) The 
 report required by subdivision 2 must describe the local 
 government core public health functions of:  assessment of 
 community health needs; goal-determination, public policy, and 
 program development for addressing these needs; and assurance of 
 service availability and accessibility to meet community health 
 goals and needs.  The report must further describe activities 
 for implementation of these functions that are the continuing 
 responsibility of the local government public health system, 
 taking into account the ongoing reform of the health care 
 delivery system. 

    (b) The activities to be defined in terms of the local 
 government core public health functions include, but are not 
 limited to: 

    (1) consumer protection and advocacy; 

    (2) targeted outreach and linkage to personal services; 

    (3) health status monitoring and disease surveillance; 

    (4) investigation and control of diseases and injuries; 

    (5) protection of the environment, work places, housing, 
 food, and water; 

    (6) laboratory services to support disease control and 
 environmental protection; 

    (7) health education and information; 

    (8) community mobilization for health-related issues; 

    (9) training and education of public health professionals; 

    (10) public health leadership and administration; 

    (11) emergency medical services; 

    (12) violence prevention; and 

    (13) other activities that have the potential to improve 
 the health of the population or special needs populations and 
 reduce the need for or cost of health care services. 

    Subd. 4.    Capacity building, accountability and funding. 
  The recommendations required by subdivision 2 shall include: 

    (1) a definition of minimum outcomes for implementing core 
 public health functions, including a local ombudsperson under 
 the assurance of services function; 

    (2) the identification of counties and applicable cities 
 with public health programs that need additional assistance to 
 meet the minimum outcomes; 

    (3) a budget for supporting all functions needed to achieve 
 the minimum outcomes, including the local ombudsperson assurance 
 of services function; 

    (4) an analysis of the costs and benefits expected from 
 achieving the minimum outcomes; 

    (5) strategies for improving local government public health 
 functions throughout the state to meet the minimum outcomes 
 including:  (i) funding distribution for local government public 
 health functions necessary to meet the minimum outcomes; and (ii)
 strategies for the financing of personal health care services 
 through the health plan companies and identifying appropriate 
 mechanisms for the delivery of these services; and 

    (6) a recommended level of dedicated funding for local 
 government public health functions in terms of a percentage of 
 total health service expenditures by the state or in terms of a 
 per capita basis, including methods of allocating the dedicated 
 funds to local government.  Funding recommendations must be 
 broad-based and must consider all financial resources. 

    Subd. 5.    Timeline.  (a) MS 2000 Obsolete 

    (b) By January 15, 1997, and by January 15 of each 
 odd-numbered year thereafter, the commissioner shall present to 
 the legislature an updated report and recommendations. 

    HIST: 1994 c 625 art 7 s 3; 1995 c 234 art 8 s 19,20; 1997 c 
 225 art 2 s 43 

     62Q.37 Audits conducted by nationally recognized 
  independent organization. 

    Subdivision 1.    Applicability.  This section applies 
 only to (i) a nonprofit health service plan corporation 
 operating under chapter 62C; (ii) a health maintenance 
 organization operating under chapter 62D; (iii) a community 
 integrated service network operating under chapter 62N; and (iv) 
 managed care organizations operating under chapter 256B, 256D, 
 or 256L. 

    Subd. 2.    Definitions.  For purposes of this section, 
 the following terms have the meanings given them. 

    (a) "Commissioner" means the commissioner of health for 
 purposes of regulating health maintenance organizations and 
 community integrated service networks, the commissioner of 
 commerce for purposes of regulating nonprofit health service 
 plan corporations, or the commissioner of human services for the 
 purpose of contracting with managed care organizations serving 
 persons enrolled in programs under chapter 256B, 256D, or 256L. 

    (b) "Health plan company" means (i) a nonprofit health 
 service plan corporation operating under chapter 62C; (ii) a 
 health maintenance organization operating under chapter 62D; 
 (iii) a community integrated service network operating under 
 chapter 62N; or (iv) a managed care organization operating under 
 chapter 256B, 256D, or 256L. 

    (c) "Nationally recognized independent organization" means 
 (i) an organization that sets specific national standards 
 governing health care quality assurance processes, utilization 
 review, provider credentialing, marketing, and other topics 
 covered by this chapter and other chapters and audits and 
 provides accreditation to those health plan companies that meet 
 those standards.  The American Accreditation Health Care 
 Commission (URAC), the National Committee for Quality Assurance 
 (NCQA), and the Joint Commission on Accreditation of Healthcare 
 Organizations (JCAHO) are, at a minimum, defined as nationally 
 recognized independent organizations; and (ii) the Centers for 
 Medicare and Medicaid Services for purposes of reviews or audits 
 conducted of health plan companies under Part C of Title XVIII 
 of the Social Security Act or under section 1876 of the Social 
 Security Act. 

    (d) "Performance standard" means those standards relating 
 to quality management and improvement, access and availability 
 of service, utilization review, provider selection, provider 
 credentialing, marketing, member rights and responsibilities, 
 complaints, appeals, grievance systems, enrollee information and 
 materials, enrollment and disenrollment, subcontractual 
 relationships and delegation, confidentiality, continuity and 
 coordination of care, assurance of adequate capacity and 
 services, coverage and authorization of services, practice 
 guidelines, health information systems, and financial solvency. 

    Subd. 3.    Audits.  (a) The commissioner may conduct 
 routine audits and investigations as prescribed under the 
 commissioner's respective state authorizing statutes.  If a 
 nationally recognized independent organization has conducted an 
 audit of the health plan company using audit procedures that are 
 comparable to or more stringent than the commissioner's audit 
 procedures: 

    (1) the commissioner may accept the independent audit and 
 require no further audit if the results of the independent audit 
 show that the performance standard being audited meets or 
 exceeds state standards; 

    (2) the commissioner may accept the independent audit and 
 limit further auditing if the results of the independent audit 
 show that the performance standard being audited partially meets 
 state standards; 

    (3) the health plan company must demonstrate to the 
 commissioner that the nationally recognized independent 
 organization that conducted the audit is qualified and that the 
 results of the audit demonstrate that the particular performance 
 standard partially or fully meets state standards; and 

    (4) if the commissioner has partially or fully accepted an 
 independent audit of the performance standard, the commissioner 
 may use the finding of a deficiency with regard to statutes or 
 rules by an independent audit as the basis for a targeted audit 
 or enforcement action. 

    (b) If a health plan company has formally delegated 
 activities that are required under either state law or contract 
 to another organization that has undergone an audit by a 
 nationally recognized independent organization, that health plan 
 company may use the nationally recognized accrediting body's 
 determination on its own behalf under this section. 

    Subd. 4.    Disclosure of national standards and reports. 
  The health plan company shall: 

    (1) request that the nationally recognized independent 
 organization provide to the commissioner a copy of the current 
 nationally recognized independent organization's standards upon 
 which the acceptable accreditation status has been granted; and 

    (2) provide the commissioner a copy of the most current 
 final audit report issued by the nationally recognized 
 independent organization. 

    Subd. 5.    Accreditation not required.  Nothing in this 
 section requires a health plan company to seek an acceptable 
 accreditation status from a nationally recognized independent 
 organization. 

    Subd. 6.    Continued authority.  Nothing in this 
 section precludes the commissioner from conducting audits and 
 investigations or requesting data as granted under the 
 commissioner's respective state authorizing statutes. 

    Subd. 7.    Human services.  (a) The commissioner of 
 human services shall implement this section in a manner that is 
 consistent with applicable federal laws and regulations and that 
 avoids the duplication of review activities performed by a 
 nationally recognized independent organization. 

    (b) By December 31 of each year, the commissioner shall 
 submit to the legislature a written report identifying the 
 number of audits performed by a nationally recognized 
 independent organization that were accepted, partially accepted, 
 or rejected by the commissioner under this section.  The 
 commissioner shall provide the rationale for partial acceptance 
 or rejection.  If the rationale for the partial acceptance or 
 rejection was based on the commissioner's determination that the 
 standards used in the audit were not equivalent to state law, 
 regulation, or contract requirement, the report must document 
 the variances between the audit standards and the applicable 
 state requirements.  

    Subd. 8.    Confidentiality.  Any documents provided to 
 the commissioner related to the audit report that may be 
 accepted under this section are private data on individuals 
 pursuant to chapter 13 and may only be released as permitted 
 under section 60A.03, subdivision 9. 

    HIST: 2004 c 288 art 6 s 8; 1Sp2005 c 4 art 8 s 4 

  62Q.41 Repealed, 1997 c 225 art 2 s 63 

     62Q.43 Geographic access. 

    Subdivision 1.    Closed-panel health plan.  For 
 purposes of this section, "closed-panel health plan" means a 
 health plan as defined in section 62Q.01 that requires an 
 enrollee to receive all or a majority of primary care services 
 from a specific clinic or physician designated by the enrollee 
 that is within the health plan company's clinic or physician 
 network. 

    Subd. 2.    Access requirement.  Every closed-panel 
 health plan must allow enrollees who are full-time students 
 under the age of 25 years to change their designated clinic or 
 physician at least once per month, as long as the clinic or 
 physician is part of the health plan company's statewide clinic 
 or physician network.  A health plan company shall not charge 
 enrollees who choose this option higher premiums or cost sharing 
 than would otherwise apply to enrollees who do not choose this 
 option.  A health plan company may require enrollees to provide 
 15 days' written notice of intent to change their designated 
 clinic or physician. 

    HIST: 1995 c 234 art 2 s 27 

     62Q.45 Coverage for out-of-area primary care. 

    Subdivision 1.    Study.  The commissioner of health 
 shall develop methods to allow enrollees of managed care 
 organizations to obtain primary care health services outside of 
 the service area of their managed care organization, from health 
 care providers who are employed by or under contract with 
 another managed care organization.  The commissioner shall make 
 recommendations on:  (1) whether this out-of-area primary care 
 coverage should be available to students and/or other enrollees 
 without additional premium charges or cost sharing; (2) methods 
 to coordinate the services provided by different managed care 
 organizations; (3) methods to manage the quality of care 
 provided by different managed care organizations and monitor 
 health care outcomes; (4) methods to reimburse managed care 
 organizations for care provided to enrollees of other managed 
 care organizations; and (5) other issues relevant to the design 
 and administration of out-of-area primary care coverage.  The 
 commissioner shall present recommendations to the legislature by 
 January 15, 1996. 

    Subd. 2.    Definition.  For purposes of this section, 
 "managed care organization" means:  

    (1) a health maintenance organization operating under 
 chapter 62D; 

    (2) a community integrated service network as defined under 
 section 62N.02, subdivision 4a; or 

    (3) an insurance company licensed under chapter 60A, 
 nonprofit health service plan corporation operating under 
 chapter 62C, fraternal benefit society operating under chapter 
 64B, or any other health plan company, to the extent that it 
 covers health care services delivered to Minnesota residents 
 through a preferred provider organization or a network of 
 selected providers.  

    HIST: 1995 c 234 art 2 s 28; 1997 c 225 art 2 s 44 

     62Q.47 Mental health and chemical dependency services. 

    (a) All health plans, as defined in section 62Q.01, that 
 provide coverage for mental health or chemical dependency 
 services, must comply with the requirements of this section. 

    (b) Cost-sharing requirements and benefit or service 
 limitations for outpatient mental health and outpatient chemical 
 dependency services, except for persons placed in chemical 
 dependency services under Minnesota Rules, parts 9530.6600 to 
 9530.6660, must not place a greater financial burden on the 
 insured or enrollee, or be more restrictive than those 
 requirements and limitations for outpatient medical services. 

    (c) Cost-sharing requirements and benefit or service 
 limitations for inpatient hospital mental health and inpatient 
 hospital and residential chemical dependency services, except 
 for persons placed in chemical dependency services under 
 Minnesota Rules, parts 9530.6600 to 9530.6660, must not place a 
 greater financial burden on the insured or enrollee, or be more 
 restrictive than those requirements and limitations for 
 inpatient hospital medical services. 

    HIST: 1995 c 234 art 2 s 29 

     62Q.471 Exclusion for suicide attempts prohibited. 

    (a) No health plan may exclude or reduce coverage for 
 health care for an enrollee who is otherwise covered under the 
 health plan on the basis that the need for the health care arose 
 out of a suicide or suicide attempt by the enrollee. 

    (b) For purposes of this section, "health plan" has the 
 meaning given in section 62Q.01, subdivision 3, but includes the 
 coverages described in section 62A.011, clauses (4), (6), and 
 (7) through (10). 

    HIST: 1Sp2001 c 9 art 9 s 1; 2002 c 379 art 1 s 113; 2005 c 
 132 s 16 

     62Q.49 Enrollee cost sharing; negotiated provider 
  payments. 

    Subdivision 1.    Applicability.  This section applies 
 to all health plans, as defined in section 62Q.01, subdivision 
 3, that provide coverage for health care to be provided entirely 
 or partially: 

    (1) through contracts in which health care providers agree 
 to accept discounted charges, negotiated charges, or other 
 limits on health care provider charges; 

    (2) by employees of, or facilities or entities owned by, 
 the issuer of the health plan; or 

    (3) through contracts with health care providers that 
 provide for payment to the providers on a fully or partially 
 capitated basis or on any other non-fee-for-service basis. 

    Subd. 2.    Disclosure required.  (a) All health plans 
 included in subdivision 1 must clearly specify how the cost of 
 health care used to calculate any co-payments, coinsurance, or 
 lifetime benefits will be affected by the arrangements described 
 in subdivision 1. 

    (b) Any summary or other marketing material used in 
 connection with marketing of a health plan that is subject to 
 this section must prominently disclose and clearly explain the 
 provisions required under paragraph (a), if the summary or other 
 marketing material refers to co-payments, coinsurance, or maximum 
 lifetime benefits. 

    (c) A health plan that is subject to paragraph (a) must not 
 be used in this state if the commissioner of commerce or health, 
 as appropriate, has determined that it does not comply with this 
 section. 

    HIST: 1996 c 446 art 1 s 50 

     62Q.50 Prostate cancer screening. 

    A health plan must cover prostate cancer screening for men 
 40 years of age or over who are symptomatic or in a high-risk 
 category and for all men 50 years of age or older. 

    The screening must consist at a minimum of a 
 prostate-specific antigen blood test and a digital rectal 
 examination. 

    This coverage is subject to any deductible, coinsurance, 
 co-payment, or other limitation on coverage applicable to other 
 coverages under the plan. 

    For purposes of this section, "health plan" includes 
 coverage that is excluded under section 62A.011, subdivision 3, 
 clauses (7) and (10). 

    HIST: 1996 c 446 art 1 s 51,72,73; 1998 c 339 s 12 

     62Q.51 Point-of-service option. 

    Subdivision 1.    Definition.  For purposes for this 
 section, "point-of-service option" means a health plan under 
 which the health plan company will reimburse an appropriately 
 licensed or registered provider for providing covered services 
 to an enrollee, without regard to whether the provider belongs 
 to a particular network and without regard to whether the 
 enrollee was referred to the provider by another provider.  

    Subd. 2.    Required point-of-service option.  Each 
 health plan company operating in the small group or large group 
 market shall offer at least one point-of-service option in each 
 such market in which it operates. 

    Subd. 3.    Rate approval.  The premium rates and cost 
 sharing requirements for each option must be submitted to the 
 commissioner of health or the commissioner of commerce as 
 required by law.  A health plan that includes lower enrollee 
 cost sharing for services provided by network providers than for 
 services provided by out-of-network providers, or lower enrollee 
 cost sharing for services provided with prior authorization or 
 second opinion than for services provided without prior 
 authorization or second opinion, qualifies as a point-of-service 
 option. 

    Subd. 4.    Exemption.  This section does not apply to a 
 health plan company with fewer than 50,000 enrollees in its 
 commercial health plan products. 

    HIST: 1996 c 446 art 1 s 52; 1999 c 181 s 6 

     62Q.52 Direct access to obstetric and gynecologic 
  services. 

    (a) Health plan companies shall allow female enrollees 
 direct access to obstetricians and gynecologists for the 
 following services: 

    (1) annual preventive health examinations, which shall 
 include a gynecologic examination, and any subsequent obstetric 
 or gynecologic visits determined to be medically necessary by 
 the examining obstetrician or gynecologist, based upon the 
 findings of the examination; 

    (2) maternity care; and 

    (3) evaluation and necessary treatment for acute 
 gynecologic conditions or emergencies. 

    (b) For purposes of this section, "direct access" means 
 that a female enrollee may obtain the obstetric and gynecologic 
 services specified in paragraph (a) from obstetricians and 
 gynecologists in the enrollee's network without a referral from, 
 or prior approval through, another physician, the health plan 
 company, or its representatives. 

    (c) Health plan companies shall not require higher 
 co-payments, coinsurance, deductibles, or other enrollee 
 cost-sharing for direct access. 

    (d) This section applies only to services described in 
 paragraph (a) that are covered by the enrollee's coverage, but 
 coverage of a preventive health examination for female enrollees 
 must not exclude coverage of a gynecologic examination. 

    HIST: 1997 c 26 s 1 

     62Q.525 Coverage for off-label drug use. 

    Subdivision 1.    Scope of coverage.  This section 
 applies to all health plans, including the coverages described 
 in section 62A.011, subdivision 3, clauses (7) and (10), that 
 are issued or renewed to a Minnesota resident.  

    Subd. 2.    Definitions.  (a) For purposes of this 
 section, the terms defined in this subdivision have the meanings 
 given them.  

    (b) "Medical literature" means articles from major peer 
 reviewed medical journals that have recognized the drug or 
 combination of drugs' safety and effectiveness for treatment of 
 the indication for which it has been prescribed.  Each article 
 shall meet the uniform requirements for manuscripts submitted to 
 biomedical journals established by the International Committee 
 of Medical Journal Editors or be published in a journal 
 specified by the United States Secretary of Health and Human 
 Services pursuant to United States Code, title 42, section 
 1395x, paragraph (t), clause (2), item (B), as amended, as 
 acceptable peer review medical literature.  Each article must 
 use generally acceptable scientific standards and must not use 
 case reports to satisfy this criterion. 

    (c) "Off-label use of drugs" means when drugs are 
 prescribed for treatments other than those stated in the 
 labeling approved by the federal Food and Drug Administration.  

    (d) "Standard reference compendia" means:  

    (1) the United States Pharmacopeia Drug Information; or 

    (2) the American Hospital Formulary Service Drug 
 Information. 

    Subd. 3.    Required coverage.  (a) Every type of 
 coverage included in subdivision 1 that provides coverage for 
 drugs may not exclude coverage of a drug for the treatment of 
 cancer on the ground that the drug has not been approved by the 
 federal Food and Drug Administration for the treatment of cancer 
 if the drug is recognized for treatment of cancer in one of the 
 standard reference compendia or in one article in the medical 
 literature, as defined in subdivision 2.  

    (b) Coverage of a drug required by this subdivision 
 includes coverage of medically necessary services directly 
 related to and required for appropriate administration of the 
 drug.  

    (c) Coverage required by this subdivision does not include 
 coverage of a drug not listed on the formulary of the coverage 
 included in subdivision 1. 

    (d) Coverage of a drug required under this subdivision must 
 not be subject to any co-payment, coinsurance, deductible, or 
 other enrollee cost-sharing greater than the coverage included 
 in subdivision 1 applies to other drugs. 

    (e) The commissioner of commerce or health, as appropriate, 
 may direct a person that issues coverage included in subdivision 
 1 to make payments required by this section.  

    Subd. 4.    Construction.  This section must not be 
 construed to:  

    (1) alter existing law limiting the coverage of drugs that 
 have not been approved by the federal Food and Drug 
 Administration; 

    (2) require coverage for any drug when the federal Food and 
 Drug Administration has determined its use to be 
 contraindicated; 

    (3) require coverage for experimental drugs not otherwise 
 approved for any indication by the federal Food and Drug 
 Administration; or 

    (4) reduce or limit coverage for off-label use of drugs 
 otherwise required by law or contract. 

    HIST: 1998 c 301 s 1 

     62Q.527 Coverage of nonformulary drugs for mental 
  illness and emotional disturbance. 

    Subdivision 1.    Definitions.  (a) For purposes of this 
 section, the following terms have the meanings given them. 

    (b) "Emotional disturbance" has the meaning given in 
 section 245.4871, subdivision 15. 

    (c) "Mental illness" has the meaning given in section 
 245.462, subdivision 20, paragraph (a). 

    (d) "Health plan" has the meaning given in section 62Q.01, 
 subdivision 3, but includes the coverages described in section 
 62A.011, subdivision 3, clauses (7) and (10).  

    Subd. 2.    Required coverage for antipsychotic drugs.  
 (a) A health plan that provides prescription drug coverage must 
 provide coverage for an antipsychotic drug prescribed to treat 
 emotional disturbance or mental illness regardless of whether 
 the drug is in the health plan's drug formulary, if the health 
 care provider prescribing the drug: 

    (1) indicates to the dispensing pharmacist, orally or in 
 writing according to section 151.21, that the prescription must 
 be dispensed as communicated; and 

    (2) certifies in writing to the health plan company that 
 the health care provider has considered all equivalent drugs in 
 the health plan's drug formulary and has determined that the 
 drug prescribed will best treat the patient's condition.  

    (b) The health plan is not required to provide coverage for 
 a drug if the drug was removed from the health plan's drug 
 formulary for safety reasons.  

    (c) For drugs covered under this section, no health plan 
 company that has received a certification from the health care 
 provider as described in paragraph (a), may: 

    (1) impose a special deductible, co-payment, coinsurance, 
 or other special payment requirement that the health plan does 
 not apply to drugs that are in the health plan's drug formulary; 
 or 

    (2) require written certification from the prescribing 
 provider each time a prescription is refilled or renewed that 
 the drug prescribed will best treat the patient's condition. 

    Subd. 3.    Continuing care.  (a) Enrollees receiving a 
 prescribed drug to treat a diagnosed mental illness or emotional 
 disturbance may continue to receive the prescribed drug for up 
 to one year without the imposition of a special deductible, 
 co-payment, coinsurance, or other special payment requirements, 
 when a health plan's drug formulary changes or an enrollee 
 changes health plans and the medication has been shown to 
 effectively treat the patient's condition.  In order to be 
 eligible for this continuing care benefit: 

    (1) the patient must have been treated with the drug for 90 
 days prior to a change in a health plan's drug formulary or a 
 change in the enrollee's health plan; 

    (2) the health care provider prescribing the drug indicates 
 to the dispensing pharmacist, orally or in writing according to 
 section 151.21, that the prescription must be dispensed as 
 communicated; and 

    (3) the health care provider prescribing the drug certifies 
 in writing to the health plan company that the drug prescribed 
 will best treat the patient's condition.  

    (b) The continuing care benefit shall be extended annually 
 when the health care provider prescribing the drug: 

    (1) indicates to the dispensing pharmacist, orally or in 
 writing according to section 151.21, that the prescription must 
 be dispensed as communicated; and 

    (2) certifies in writing to the health plan company that 
 the drug prescribed will best treat the patient's condition.  

    (c) The health plan company is not required to provide 
 coverage for a drug if the drug was removed from the health 
 plan's drug formulary for safety reasons.  

    Subd. 4.    Exception to formulary.  A health plan 
 company must promptly grant an exception to the health plan's 
 drug formulary for an enrollee when the health care provider 
 prescribing the drug indicates to the health plan company that: 

    (1) the formulary drug causes an adverse reaction in the 
 patient; 

    (2) the formulary drug is contraindicated for the patient; 
 or 

    (3) the health care provider demonstrates to the health 
 plan that the prescription drug must be dispensed as written to 
 provide maximum medical benefit to the patient. 

    HIST: 1Sp2001 c 9 art 9 s 2; 2002 c 379 art 1 s 113 

     62Q.53 Mental health coverage; minimum standards for 
  medically necessary care. 

    Subdivision 1.    Requirement.  No health plan that 
 covers mental health services may be offered, sold, issued, or 
 renewed in this state that requires mental health services to 
 satisfy a definition of "medically necessary care," "medical 
 necessity," or similar term that is more restrictive with 
 respect to mental health than the definition provided in 
 subdivision 2. 

    Subd. 2.    Minimum definition.  "Medically necessary 
 care" means health care services appropriate, in terms of type, 
 frequency, level, setting, and duration, to the enrollee's 
 diagnosis or condition, and diagnostic testing and preventive 
 services.  Medically necessary care must be consistent with 
 generally accepted practice parameters as determined by health 
 care providers in the same or similar general specialty as 
 typically manages the condition, procedure, or treatment at 
 issue and must: 

    (1) help restore or maintain the enrollee's health; or 

    (2) prevent deterioration of the enrollee's condition.  

    Subd. 3.    Health plan; definition.  For purposes of 
 this section, "health plan" has the meaning given in section 
 62Q.01, subdivision 3, but includes the coverages listed in 
 section 62A.011, subdivision 3, clauses (7) and (10). 

    HIST: 1997 c 49 s 1 

     62Q.535 Coverage for court-ordered mental health 
  services. 

    Subdivision 1.    Mental health services.  For purposes 
 of this section, mental health services means all covered 
 services that are intended to treat or ameliorate an emotional, 
 behavioral, or psychiatric condition and that are covered by the 
 policy, contract, or certificate of coverage of the enrollee's 
 health plan company or by law. 

    Subd. 2.    Coverage required.  (a) All health plan 
 companies that provide coverage for mental health services must 
 cover or provide mental health services ordered by a court of 
 competent jurisdiction under a court order that is issued on the 
 basis of a behavioral care evaluation performed by a licensed 
 psychiatrist or a doctoral level licensed psychologist, which 
 includes a diagnosis and an individual treatment plan for care 
 in the most appropriate, least restrictive environment.  The 
 health plan company must be given a copy of the court order and 
 the behavioral care evaluation.  The health plan company shall 
 be financially liable for the evaluation if performed by a 
 participating provider of the health plan company and shall be 
 financially liable for the care included in the court-ordered 
 individual treatment plan if the care is covered by the health 
 plan and ordered to be provided by a participating provider or 
 another provider as required by rule or law.  This court-ordered 
 coverage must not be subject to a separate medical necessity 
 determination by a health plan company under its utilization 
 procedures.  

    (b) A party or interested person, including a health plan 
 company or its designee, may make a motion for modification of 
 the court-ordered plan of care pursuant to the applicable rules 
 of procedure for modification of the court's order.  The motion 
 may include a request for a new behavioral care evaluation 
 according to this section. 

    HIST: 1Sp2001 c 9 art 9 s 3; 2002 c 379 art 1 s 113 

     62Q.54 Referrals for residents of health care facilities.

    If an enrollee is a resident of a health care facility 
 licensed under chapter 144A or a housing with services 
 establishment registered under chapter 144D, the enrollee's 
 primary care physician must refer the enrollee to that 
 facility's skilled nursing unit or that facility's appropriate 
 care setting, provided that the health plan company and the 
 provider can best meet the patient's needs in that setting, if 
 the following conditions are met: 

    (1) the facility agrees to be reimbursed at that health 
 plan company's contract rate negotiated with similar providers 
 for the same services and supplies; and 

    (2) the facility meets all guidelines established by the 
 health plan company related to quality of care, utilization, 
 referral authorization, risk assumption, use of health plan 
 company network, and other criteria applicable to providers 
 under contract for the same services and supplies. 

    HIST: 1997 c 225 art 2 s 45 

     62Q.55 Emergency services. 

    (a) Enrollees have the right to available and accessible 
 emergency services, 24 hours a day and seven days a week.  The 
 health plan company shall inform its enrollees how to obtain 
 emergency care and, if prior authorization for emergency 
 services is required, shall make available a toll-free number, 
 which is answered 24 hours a day, to answer questions about 
 emergency services and to receive reports and provide 
 authorizations, where appropriate, for treatment of emergency 
 medical conditions.  Emergency services shall be covered whether 
 provided by participating or nonparticipating providers and 
 whether provided within or outside the health plan company's 
 service area.  In reviewing a denial for coverage of emergency 
 services, the health plan company shall take the following 
 factors into consideration: 

    (1) a reasonable layperson's belief that the circumstances 
 required immediate medical care that could not wait until the 
 next working day or next available clinic appointment; 

    (2) the time of day and day of the week the care was 
 provided; 

    (3) the presenting symptoms, including, but not limited to, 
 severe pain, to ensure that the decision to reimburse the 
 emergency care is not made solely on the basis of the actual 
 diagnosis; 

    (4) the enrollee's efforts to follow the health plan 
 company's established procedures for obtaining emergency care; 
 and 

    (5) any circumstances that precluded use of the health plan 
 company's established procedures for obtaining emergency care. 

    (b) The health plan company may require enrollees to notify 
 the health plan company of nonreferred emergency care as soon as 
 possible, but not later than 48 hours, after the emergency care 
 is initially provided.  However, emergency care which would have 
 been covered under the contract had notice been provided within 
 the set time frame must be covered. 

    (c) Notwithstanding paragraphs (a) and (b), a health plan 
 company, health insurer, or health coverage plan that is in 
 compliance with the rules regarding accessibility of services 
 adopted under section 62D.20 is in compliance with this section. 

    HIST: 1997 c 237 s 11 

     62Q.56 Continuity of care. 

    Subdivision 1.    Change in health care provider; general 
 notification.  (a) If enrollees are required to access 
 services through selected primary care providers for coverage, 
 the health plan company shall prepare a written plan that 
 provides for continuity of care in the event of contract 
 termination between the health plan company and any of the 
 contracted primary care providers, specialists, or general 
 hospital providers.  The written plan must explain: 

    (1) how the health plan company will inform affected 
 enrollees about termination at least 30 days before the 
 termination is effective, if the health plan company or health 
 care network cooperative has received at least 120 days' prior 
 notice; 

    (2) how the health plan company will inform the affected 
 enrollees about what other participating providers are available 
 to assume care and how it will facilitate an orderly transfer of 
 its enrollees from the terminating provider to the new provider 
 to maintain continuity of care; 

    (3) the procedures by which enrollees will be transferred 
 to other participating providers, when special medical needs, 
 special risks, or other special circumstances, such as cultural 
 or language barriers, require them to have a longer transition 
 period or be transferred to nonparticipating providers; 

    (4) who will identify enrollees with special medical needs 
 or at special risk and what criteria will be used for this 
 determination; and 

    (5) how continuity of care will be provided for enrollees 
 identified as having special needs or at special risk, and 
 whether the health plan company has assigned this responsibility 
 to its contracted primary care providers. 

    (b) For purposes of this section, contract termination 
 includes nonrenewal.  

    Subd. 1a.    Change in health care provider; termination 
 not for cause.  (a) If the contract termination was not for 
 cause and the contract was terminated by the health plan 
 company, the health plan company must provide the terminated 
 provider and all enrollees being treated by that provider with 
 notification of the enrollees' rights to continuity of care with 
 the terminated provider.  

    (b) The health plan company must provide, upon request, 
 authorization to receive services that are otherwise covered 
 under the terms of the health plan through the enrollee's 
 current provider: 

    (1) for up to 120 days if the enrollee is engaged in a 
 current course of treatment for one or more of the following 
 conditions: 

    (i) an acute condition; 

    (ii) a life-threatening mental or physical illness; 

    (iii) pregnancy beyond the first trimester of pregnancy; 

    (iv) a physical or mental disability defined as an 
 inability to engage in one or more major life activities, 
 provided that the disability has lasted or can be expected to 
 last for at least one year, or can be expected to result in 
 death; or 

    (v) a disabling or chronic condition that is in an acute 
 phase; or 

    (2) for the rest of the enrollee's life if a physician 
 certifies that the enrollee has an expected lifetime of 180 days 
 or less.  

 For all requests for authorization to receive services under 
 this paragraph, the health plan company must grant the request 
 unless the enrollee does not meet the criteria provided in this 
 paragraph. 

    (c) The health plan company shall prepare a written plan 
 that provides a process for coverage determinations regarding 
 continuity of care of up to 120 days for enrollees who request 
 continuity of care with their former provider, if the enrollee: 

    (1) is receiving culturally appropriate services and the 
 health plan company does not have a provider in its preferred 
 provider network with special expertise in the delivery of those 
 culturally appropriate services within the time and distance 
 requirements of section 62D.124, subdivision 1; or 

    (2) does not speak English and the health plan company does 
 not have a provider in its preferred provider network who can 
 communicate with the enrollee, either directly or through an 
 interpreter, within the time and distance requirements of 
 section 62D.124, subdivision 1. 

 The written plan must explain the criteria that will be used to 
 determine whether a need for continuity of care exists and how 
 it will be provided.  

    Subd. 1b.    Change in health care provider; termination 
 for cause.  If the contract termination was for cause, 
 enrollees must be notified of the change and transferred to 
 participating providers in a timely manner so that health care 
 services remain available and accessible to the affected 
 enrollees.  The health plan company is not required to refer an 
 enrollee back to the terminating provider if the termination was 
 for cause. 

    Subd. 2.    Change in health plans.  (a) If an enrollee 
 is subject to a change in health plans, the enrollee's new 
 health plan company must provide, upon request, authorization to 
 receive services that are otherwise covered under the terms of 
 the new health plan through the enrollee's current provider: 

    (1) for up to 120 days if the enrollee is engaged in a 
 current course of treatment for one or more of the following 
 conditions: 

    (i) an acute condition; 

    (ii) a life-threatening mental or physical illness; 

    (iii) pregnancy beyond the first trimester of pregnancy; 

    (iv) a physical or mental disability defined as an 
 inability to engage in one or more major life activities, 
 provided that the disability has lasted or can be expected to 
 last for at least one year, or can be expected to result in 
 death; or 

    (v) a disabling or chronic condition that is in an acute 
 phase; or 

    (2) for the rest of the enrollee's life if a physician 
 certifies that the enrollee has an expected lifetime of 180 days 
 or less.  

 For all requests for authorization under this paragraph, the 
 health plan company must grant the request for authorization 
 unless the enrollee does not meet the criteria provided in this 
 paragraph. 

    (b) The health plan company shall prepare a written plan 
 that provides a process for coverage determinations regarding 
 continuity of care of up to 120 days for new enrollees who 
 request continuity of care with their former provider, if the 
 new enrollee: 

    (1) is receiving culturally appropriate services and the 
 health plan company does not have a provider in its preferred 
 provider network with special expertise in the delivery of those 
 culturally appropriate services within the time and distance 
 requirements of section 62D.124, subdivision 1; or 

    (2) does not speak English and the health plan company does 
 not have a provider in its preferred provider network who can 
 communicate with the enrollee, either directly or through an 
 interpreter, within the time and distance requirements of 
 section 62D.124, subdivision 1. 

 The written plan must explain the criteria that will be used to 
 determine whether a need for continuity of care exists and how 
 it will be provided. 

    (c) This subdivision applies only to group coverage and 
 continuation and conversion coverage, and applies only to 
 changes in health plans made by the employer. 

    Subd. 2a.    Limitations.  (a) Subdivisions 1, 1a, 1b, 
 and 2 apply only if the enrollee's health care provider agrees 
 to: 

    (1) accept as payment in full the lesser of the health plan 
 company's reimbursement rate for in-network providers for the 
 same or similar service or the enrollee's health care provider's 
 regular fee for that service; 

    (2) adhere to the health plan company's preauthorization 
 requirements; and 

    (3) provide the health plan company with all necessary 
 medical information related to the care provided to the enrollee.

    (b) Nothing in this section requires a health plan company 
 to provide coverage for a health care service or treatment that 
 is not covered under the enrollee's health plan.  

    Subd. 2b.    Request for authorization.  The health plan 
 company may require medical records and other supporting 
 documentation to be submitted with the requests for 
 authorization made under subdivision 1, 1a, 1b, or 2.  If the 
 authorization is denied, the health plan company must explain 
 the criteria it used to make its decision on the request for 
 authorization.  If the authorization is granted, the health plan 
 company must explain how continuity of care will be provided. 

    Subd. 3.    Disclosure.  Information regarding an 
 enrollee's rights under this section must be included in member 
 contracts or certificates of coverage and must be provided by a 
 health plan company upon request of an enrollee or prospective 
 enrollee. 

    HIST: 1997 c 237 s 12; 1Sp2001 c 9 art 16 s 7; 2002 c 379 art 
 1 s 113 

     62Q.58 Access to specialty care. 

    Subdivision 1.    Standing referral.  A health plan 
 company shall establish a procedure by which an enrollee may 
 apply for and, if appropriate, receive a standing referral to a 
 health care provider who is a specialist if a referral to a 
 specialist is required for coverage.  This procedure for a 
 standing referral must specify the necessary managed care review 
 and approval an enrollee must obtain before such a standing 
 referral is permitted. 

    Subd. 1a.    Mandatory standing referral.  (a) An 
 enrollee who requests a standing referral to a specialist 
 qualified to treat the specific condition described in clauses 
 (1) to (5) must be given a standing referral for visits to such 
 a specialist if benefits for such treatment are provided under 
 the health plan and the enrollee has any of the following 
 conditions: 

    (1) a chronic health condition; 

    (2) a life-threatening mental or physical illness; 

    (3) pregnancy beyond the first trimester of pregnancy; 

    (4) a degenerative disease or disability; or 

    (5) any other condition or disease of sufficient 
 seriousness and complexity to require treatment by a specialist. 

    (b) Nothing in this section limits the application of 
 section 62Q.52 specifying direct access to obstetricians and 
 gynecologists. 

    (c) Paragraph (a) does not apply to health plans issued 
 under sections 43A.23 to 43A.31. 

    Subd. 2.    Coordination of services.  An enrollee with 
 a standing referral to a specialist may request primary care 
 services from that specialist.  The specialist, in agreement 
 with the enrollee and primary care provider or primary care 
 group, may elect to provide primary care services to the 
 enrollee, authorize tests and services, and make secondary 
 referrals according to procedures established by the health plan 
 company.  The health plan company may limit the primary care 
 services, tests and services, and secondary referrals authorized 
 under this subdivision to those that are related to the specific 
 condition or conditions for which the standing referral was made.

    Subd. 3.    Disclosure.  Information regarding referral 
 procedures must be included in member contracts or certificates 
 of coverage and must be provided to an enrollee or prospective 
 enrollee by a health plan company upon request. 

    Subd. 4.    Referral.  (a) If a standing referral is 
 authorized under subdivision 1 or is mandatory under subdivision 
 1a, the health plan company must provide a referral to an 
 appropriate participating specialist who is reasonably available 
 and accessible to provide the treatment or to a nonparticipating 
 specialist if the health plan company does not have an 
 appropriate participating specialist who is reasonably available 
 and accessible to treat the enrollee's condition or disease. 

    (b) If an enrollee receives services from a 
 nonparticipating specialist because a participating specialist 
 is not available, services must be provided at no additional 
 cost to the enrollee beyond what the enrollee would otherwise 
 pay for services received from a participating specialist. 

    HIST: 1997 c 237 s 13; 1Sp2001 c 9 art 16 s 8; 2002 c 379 art 
 1 s 113 

     62Q.64 Disclosure of executive compensation. 

    (a) Each health plan company doing business in this state 
 shall annually file with the Consumer Advisory Board created in 
 section 62J.75: 

    (1) a copy of the health plan company's form 990 filed with 
 the federal Internal Revenue Service; or 

    (2) if the health plan company did not file a form 990 with 
 the federal Internal Revenue Service, a list of the amount and 
 recipients of the health plan company's five highest salaries, 
 including all types of compensation, in excess of $50,000. 

    (b) A filing under this section is public data under 
 section 13.03. 

    HIST: 1997 c 237 s 14 

     62Q.65 Access to provider discounts. 

    Subdivision 1.    Requirement.  A high deductible health 
 plan must, when used in connection with a medical savings 
 account or health savings account, provide the enrollee access 
 to any discounted provider fees for services covered by the high 
 deductible health plan, regardless of whether the enrollee has 
 satisfied the deductible for the high deductible health plan. 

    Subd. 2.    Definitions.  For purposes of this section, 
 the following terms have the meanings given: 

    (1) "high deductible health plan" has the meaning given 
 under the Internal Revenue Code of 1986, section 220(c)(2), with 
 respect to a medical savings account; and the meaning given 
 under Internal Revenue Code of 1986, section 223(c)(2), with 
 respect to a health savings account; 

    (2) "medical savings account" has the meaning given under 
 the Internal Revenue Code of 1986, section 220(d)(1); 

    (3) "discounted provider fees" means fees contained in a 
 provider agreement entered into by the issuer of the high 
 deductible health plan, or an affiliate of the issuer, for use 
 in connection with the high deductible health plan; and 

    (4) "health savings account" has the meaning given under 
 the Internal Revenue Code of 1986, section 223(d). 

    HIST: 1997 c 225 art 2 s 46; 2005 c 132 s 17 

     62Q.66 Durable medical equipment coverage. 

    No health plan company that covers durable medical 
 equipment may utilize medical coverage criteria for durable 
 medical equipment that limits coverage solely to equipment used 
 in the home. 

    HIST: 1998 c 334 s 1 

     62Q.67 Disclosure of covered durable medical equipment. 

    Subdivision 1.    Disclosure.  A health plan company 
 that covers durable medical equipment shall provide enrollees, 
 and upon request prospective enrollees, written disclosure that 
 includes the information set forth in subdivision 2.  The health 
 plan company may include the information in the member contract, 
 certificate of coverage, schedule of payments, member handbook, 
 or other written enrollee communication. 

    Subd. 2.    Information to be disclosed.  A health plan 
 company that covers durable medical equipment shall disclose the 
 following information: 

    (a) general descriptions of the coverage for durable 
 medical equipment, level of coverage available, and criteria and 
 procedures for any required prior authorizations; and 

    (b) the address and telephone number of a health plan 
 representative whom an enrollee may contact to obtain specific 
 information verbally, or upon request in writing, about prior 
 authorization including criteria used in making coverage 
 decisions and information on limitations or exclusions for 
 durable medical equipment. 

    HIST: 1998 c 334 s 2 

     62Q.675 Hearing aids; persons 18 or younger. 

    A health plan must cover hearing aids for individuals 18 
 years of age or younger for hearing loss due to functional 
 congenital malformation of the ears that is not correctable by 
 other covered procedures.  Coverage required under this section 
 is limited to one hearing aid in each ear every three years.  No 
 special deductible, coinsurance, co-payment, or other limitation 
 on the coverage under this section that is not generally 
 applicable to other coverages under the plan may be imposed. 

    HIST: 1Sp2003 c 14 art 7 s 24 

COMPLAINT RESOLUTION

     62Q.68 Definitions. 

    Subdivision 1.    Application.  For purposes of sections 
 62Q.68 to 62Q.72, the terms defined in this section have the 
 meanings given them.  For purposes of sections 62Q.69 and 
 62Q.70, the term "health plan company" does not include an 
 insurance company licensed under chapter 60A to offer, sell, or 
 issue a policy of accident and sickness insurance as defined in 
 section 62A.01 or a nonprofit health service plan corporation 
 regulated under chapter 62C that only provides dental coverage 
 or vision coverage.  For purposes of sections 62Q.69 through 
 62Q.73, the term "health plan company" does not include the 
 Comprehensive Health Association created under chapter 62E. 

    Subd. 2.    Complaint.  "Complaint" means any grievance 
 against a health plan company that is not the subject of 
 litigation and that has been submitted by a complainant to a 
 health plan company regarding the provision of health services 
 including, but not limited to, the scope of coverage for health 
 care services; retrospective denials or limitations of payment 
 for services; eligibility issues; denials, cancellations, or 
 nonrenewals of coverage; administrative operations; and the 
 quality, timeliness, and appropriateness of health care services 
 rendered.  If the complaint is from an applicant, the complaint 
 must relate to the application.  If the complaint is from a 
 former enrollee, the complaint must relate to services received 
 during the period of time the individual was an enrollee.  Any 
 grievance requiring a medical determination in its resolution 
 must have the medical determination aspect of the complaint 
 processed under the appeal procedure described in section 62M.06.

    Subd. 3.    Complainant.  "Complainant" means an 
 enrollee, applicant, or former enrollee, or anyone acting on 
 behalf of an enrollee, applicant, or former enrollee, who 
 submits a complaint. 

    HIST: 1999 c 239 s 34; 2002 c 330 s 28 

     62Q.69 Complaint resolution. 

    Subdivision 1.    Establishment.  Each health plan 
 company must establish and maintain an internal complaint 
 resolution process that meets the requirements of this section 
 to provide for the resolution of a complaint initiated by a 
 complainant. 

    Subd. 2.    Procedures for filing a complaint.  (a) A 
 complainant may submit a complaint to a health plan company 
 either by telephone or in writing.  If a complaint is submitted 
 orally and the resolution of the complaint, as determined by the 
 complainant, is partially or wholly adverse to the complainant, 
 or the oral complaint is not resolved to the satisfaction of the 
 complainant, by the health plan company within ten days of 
 receiving the complaint, the health plan company must inform the 
 complainant that the complaint may be submitted in writing.  The 
 health plan company must also offer to provide the complainant 
 with any assistance needed to submit a written complaint, 
 including an offer to complete the complaint form for a 
 complaint that was previously submitted orally and promptly mail 
 the completed form to the complainant for the complainant's 
 signature.  At the complainant's request, the health plan 
 company must provide the assistance requested by the 
 complainant.  The complaint form must include the following 
 information: 

    (1) the telephone number of the Office of Health Care 
 Consumer Assistance, Advocacy, and Information, and the health 
 plan company member services or other departments or persons 
 equipped to advise complainants on complaint resolution; 

    (2) the address to which the form must be sent; 

    (3) a description of the health plan company's internal 
 complaint procedure and the applicable time limits; and 

    (4) the toll-free telephone number of either the 
 commissioner of health or commerce and notification that the 
 complainant has the right to submit the complaint at any time to 
 the appropriate commissioner for investigation. 

    (b) Upon receipt of a written complaint, the health plan 
 company must notify the complainant within ten business days 
 that the complaint was received, unless the complaint is 
 resolved to the satisfaction of the complainant within the ten 
 business days. 

    (c) Each health plan company must provide, in the member 
 handbook, subscriber contract, or certification of coverage, a 
 clear and concise description of how to submit a complaint and a 
 statement that, upon request, assistance in submitting a written 
 complaint is available from the health plan company. 

    Subd. 3.    Notification of complaint decisions.  (a) 
 The health plan company must notify the complainant in writing 
 of its decision and the reasons for it as soon as practical but 
 in no case later than 30 days after receipt of a written 
 complaint. If the health plan company cannot make a decision 
 within 30 days due to circumstances outside the control of the 
 health plan company, the health plan company may take up to 14 
 additional days to notify the complainant of its decision.  If 
 the health plan company takes any additional days beyond the 
 initial 30-day period to make its decision, it must inform the 
 complainant, in advance, of the extension and the reasons for 
 the extension.  

    (b) If the decision is partially or wholly adverse to the 
 complainant, the notification must inform the complainant of the 
 right to appeal the decision to the health plan company's 
 internal appeal process described in section 62Q.70 and the 
 procedure for initiating an appeal.  

    (c) The notification must also inform the complainant of 
 the right to submit the complaint at any time to either the 
 commissioner of health or commerce for investigation and the 
 toll-free telephone number of the appropriate commissioner. 

    HIST: 1999 c 239 s 35 

     62Q.70 Appeal of the complaint decision. 

    Subdivision 1.    Establishment.  (a) Each health plan 
 company shall establish an internal appeal process for reviewing 
 a health plan company's decision regarding a complaint filed in 
 accordance with section 62Q.69.  The appeal process must meet 
 the requirements of this section.  

    (b) The person or persons with authority to resolve or 
 recommend the resolution of the internal appeal must not be 
 solely the same person or persons who made the complaint 
 decision under section 62Q.69. 

    (c) The internal appeal process must permit the receipt of 
 testimony, correspondence, explanations, or other information 
 from the complainant, staff persons, administrators, providers, 
 or other persons as deemed necessary by the person or persons 
 investigating or presiding over the appeal. 

    Subd. 2.    Procedures for filing an appeal.  If a 
 complainant notifies the health plan company of the 
 complainant's desire to appeal the health plan company's 
 decision regarding the complaint through the internal appeal 
 process, the health plan company must provide the complainant 
 the option for the appeal to occur either in writing or by 
 hearing. 

    Subd. 3.    Notification of appeal decisions.  (a) If a 
 complainant appeals in writing, the health plan company must 
 give the complainant written notice of the appeal decision and 
 all key findings within 30 days of the health plan company's 
 receipt of the complainant's written notice of appeal.  If a 
 complainant appeals by hearing, the health plan company must 
 give the complainant written notice of the appeal decision and 
 all key findings within 45 days of the health plan company's 
 receipt of the complainant's written notice of appeal. 

    (b) If the appeal decision is partially or wholly adverse 
 to the complainant, the notice must advise the complainant of 
 the right to submit the appeal decision to the external review 
 process described in section 62Q.73 and the procedure for 
 initiating the external process. 

    (c) Upon the request of the complainant, the health plan 
 company must provide the complainant with a complete summary of 
 the appeal decision.  

    HIST: 1999 c 239 s 36 

     62Q.71 Notice to enrollees. 

    Each health plan company shall provide to enrollees a clear 
 and concise description of its complaint resolution procedure, 
 if applicable under section 62Q.68, subdivision 1, and the 
 procedure used for utilization review as defined under chapter 
 62M as part of the member handbook, subscriber contract, or 
 certificate of coverage.  If the health plan company does not 
 issue a member handbook, the health plan company may provide the 
 description in another written document.  The description must 
 specifically inform enrollees:  

    (1) how to submit a complaint to the health plan company; 

    (2) if the health plan includes utilization review 
 requirements, how to notify the utilization review organization 
 in a timely manner and how to obtain certification for health 
 care services; 

    (3) how to request an appeal either through the procedures 
 described in sections 62Q.69 and 62Q.70 or through the 
 procedures described in chapter 62M; 

    (4) of the right to file a complaint with either the 
 commissioner of health or commerce at any time during the 
 complaint and appeal process; 

    (5) of the toll-free telephone number of the appropriate 
 commissioner; and 

    (6) of the right to obtain an external review under section 
 62Q.73 and a description of when and how that right may be 
 exercised. 

    HIST: 1999 c 239 s 37; 2003 c 2 art 1 s 8 

     62Q.72 Record keeping; reporting. 

    Subdivision 1.    Record keeping.  Each health plan 
 company shall maintain records of all enrollee complaints and 
 their resolutions.  These records shall be retained for five 
 years and shall be made available to the appropriate 
 commissioner upon request.  An insurance company licensed under 
 chapter 60A may instead comply with section 72A.20, subdivision 
 30. 

    Subd. 2.    Reporting.  Each health plan company shall 
 submit to the appropriate commissioner, as part of the company's 
 annual filing, data on the number and type of complaints that 
 are not resolved within 30 days, or 30 business days as provided 
 under section 72A.201, subdivision 4, clause (3), for insurance 
 companies licensed under chapter 60A.  The commissioner shall 
 also make this information available to the public upon request. 

    HIST: 1999 c 239 s 38 

     62Q.73 External review of adverse determinations. 

    Subdivision 1.    Definition.  For purposes of this 
 section, "adverse determination" means:  

    (1) a complaint decision relating to a health care service 
 or claim that has been appealed in accordance with section 
 62Q.70 and the appeal decision is partially or wholly adverse to 
 the complainant; 

    (2) any initial determination not to certify that has been 
 appealed in accordance with section 62M.06 and the appeal did 
 not reverse the initial determination not to certify; or 

    (3) a decision relating to a health care service made by a 
 health plan company licensed under chapter 60A that denies the 
 service on the basis that the service was not medically 
 necessary. 

 An adverse determination does not include complaints relating to 
 fraudulent marketing practices or agent misrepresentation. 

    Subd. 2.    Exception.  (a) This section does not apply 
 to governmental programs except as permitted under paragraph (b).
 For purposes of this subdivision, "governmental programs" means 
 the prepaid medical assistance program, the MinnesotaCare 
 program, the prepaid general assistance medical care program, 
 the demonstration project for people with disabilities, and the 
 federal Medicare program. 

    (b) In the course of a recipient's appeal of a medical 
 determination to the commissioner of human services under 
 section 256.045, the recipient may request an expert medical 
 opinion be arranged by the external review entity under contract 
 to provide independent external reviews under this section.  If 
 such a request is made, the cost of the review shall be paid by 
 the commissioner of human services.  Any medical opinion 
 obtained under this paragraph shall only be used by a state 
 human services referee as evidence in the recipient's appeal to 
 the commissioner of human services under section 256.045.  

    (c) Nothing in this subdivision shall be construed to limit 
 or restrict the appeal rights provided in section 256.045 for 
 governmental program recipients. 

    Subd. 3.    Right to external review.  (a) Any enrollee 
 or anyone acting on behalf of an enrollee who has received an 
 adverse determination may submit a written request for an 
 external review of the adverse determination, if applicable 
 under section 62Q.68, subdivision 1, or 62M.06, to the 
 commissioner of health if the request involves a health plan 
 company regulated by that commissioner or to the commissioner of 
 commerce if the request involves a health plan company regulated 
 by that commissioner.  Notification of the enrollee's right to 
 external review must accompany the denial issued by the insurer. 
 The written request must be accompanied by a filing fee of $25.  
 The fee may be waived by the commissioner of health or commerce 
 in cases of financial hardship. 

    (b) Nothing in this section requires the commissioner of 
 health or commerce to independently investigate an adverse 
 determination referred for independent external review. 

    (c) If an enrollee requests an external review, the health 
 plan company must participate in the external review.  The cost 
 of the external review in excess of the filing fee described in 
 paragraph (a) shall be borne by the health plan company.  

    Subd. 4.    Contract.  Pursuant to a request for 
 proposal, the commissioner of administration, in consultation 
 with the commissioners of health and commerce, shall contract 
 with an organization or business entity to provide independent 
 external reviews of all adverse determinations submitted for 
 external review.  The contract shall ensure that the fees for 
 services rendered in connection with the reviews be reasonable. 

    Subd. 5.    Criteria.  (a) The request for proposal must 
 require that the entity demonstrate: 

    (1) no conflicts of interest in that it is not owned, a 
 subsidiary of, or affiliated with a health plan company or 
 utilization review organization; 

    (2) an expertise in dispute resolution; 

    (3) an expertise in health-related law; 

    (4) an ability to conduct reviews using a variety of 
 alternative dispute resolution procedures depending upon the 
 nature of the dispute; 

    (5) an ability to provide data to the commissioners of 
 health and commerce on reviews conducted; and 

    (6) an ability to ensure confidentiality of medical records 
 and other enrollee information. 

    (b) The commissioner of administration shall take into 
 consideration, in awarding the contract according to subdivision 
 4, any national accreditation standards that pertain to an 
 external review entity. 

    Subd. 6.    Process.  (a) Upon receiving a request for 
 an external review, the external review entity must provide 
 immediate notice of the review to the enrollee and to the health 
 plan company.  Within ten business days of receiving notice of 
 the review, the health plan company and the enrollee must 
 provide the external review entity with any information that 
 they wish to be considered.  Each party shall be provided an 
 opportunity to present its version of the facts and arguments.  
 An enrollee may be assisted or represented by a person of the 
 enrollee's choice. 

    (b) As part of the external review process, any aspect of 
 an external review involving a medical determination must be 
 performed by a health care professional with expertise in the 
 medical issue being reviewed. 

    (c) An external review shall be made as soon as practical 
 but in no case later than 40 days after receiving the request 
 for an external review and must promptly send written notice of 
 the decision and the reasons for it to the enrollee, the health 
 plan company, and the commissioner who is responsible for 
 regulating the health plan company. 

    Subd. 7.    Standards of review.  (a) For an external 
 review of any issue in an adverse determination that does not 
 require a medical necessity determination, the external review 
 must be based on whether the adverse determination was in 
 compliance with the enrollee's health benefit plan. 

    (b) For an external review of any issue in an adverse 
 determination by a health plan company licensed under chapter 
 62D that requires a medical necessity determination, the 
 external review must determine whether the adverse determination 
 was consistent with the definition of medically necessary care 
 in Minnesota Rules, part 4685.0100, subpart 9b. 

    (c) For an external review of any issue in an adverse 
 determination by a health plan company, other than a health plan 
 company licensed under chapter 62D, that requires a medical 
 necessity determination, the external review must determine 
 whether the adverse determination was consistent with the 
 definition of medically necessary care in section 62Q.53, 
 subdivision 2. 

    Subd. 8.    Effects of external review.  A decision 
 rendered under this section shall be nonbinding on the enrollee 
 and binding on the health plan company.  The health plan company 
 may seek judicial review of the decision on the grounds that the 
 decision was arbitrary and capricious or involved an abuse of 
 discretion. 

    Subd. 9.    Immunity from civil liability.  A person who 
 participates in an external review by investigating, reviewing 
 materials, providing technical expertise, or rendering a 
 decision shall not be civilly liable for any action that is 
 taken in good faith, that is within the scope of the person's 
 duties, and that does not constitute willful or reckless 
 misconduct. 

    Subd. 10.    Data reporting.  The commissioners shall 
 make available to the public, upon request, summary data on the 
 decisions rendered under this section, including the number of 
 reviews heard and decided and the final outcomes.  Any data 
 released to the public must not individually identify the 
 enrollee initiating the request for external review. 

    HIST: 1999 c 239 s 39; 2000 c 474 s 2; 2001 c 215 s 27 

     62Q.731 External review of adverse determination from 
  Comprehensive Health Association. 

    Subdivision 1.    Definitions.  (a) For purposes of this 
 section, the terms defined in this subdivision have the meanings 
 given. 

    (b) "Enrollee" means an eligible person as defined in 
 section 62E.02, subdivision 13, and who meets the eligibility 
 criteria established in section 62E.14. 

    (c) "Board" means the board of directors of the 
 Comprehensive Health Association, as described in section 
 62E.10, subdivision 2. 

    Subd. 2.    Appeal to external review entity.  If an 
 enrollee receives an adverse determination as a result of the 
 Comprehensive Health Association's internal appeal process, by 
 which an established enrollee appeal committee renders an 
 adverse determination, the enrollee then has the option of: 

    (1) appealing the adverse determination to the external 
 review entity under section 62Q.73, which shall constitute a 
 final determination subject to the conditions specified in 
 section 62Q.73; or 

    (2) appealing to the commissioner of commerce from an 
 adverse determination as provided by the operating rules of the 
 Comprehensive Health Association, in which case the commissioner 
 has the option of making a determination regarding the appeal, 
 or submitting the appeal to the external review entity retained 
 under section 62Q.73. 

    HIST: 2002 c 330 s 29 

MINNESOTA HEALTH PLAN CONTRACTING ACT

     62Q.732 Citation. 

    Sections 62Q.732 to 62Q.75 may be cited as the "Minnesota 
 Health Plan Contracting Act."  

    HIST: 2004 c 246 s 2 

     62Q.733 Definitions. 

    Subdivision 1.    Applicability.  For purposes of 
 sections 62Q.732 to 62Q.739, the following definitions apply.  

    Subd. 2.    Contract.  "Contract" means a written 
 agreement between a health care provider and a health plan 
 company to provide health care services.  

    Subd. 3.    Health care provider or provider.  "Health 
 care provider" or "provider" means a physician, chiropractor, 
 dentist, podiatrist, or other provider as defined under section 
 62J.03, other than hospitals, ambulatory surgical centers, or 
 freestanding emergency rooms.  

    Subd. 4.    Health plan company.  (a) "Health plan 
 company" means: 

    (1) a health maintenance organization operating under 
 chapter 62D; 

    (2) a community integrated service network operating under 
 chapter 62N; 

    (3) a preferred provider organization as defined in section 
 145.61, subdivision 4c; or 

    (4) an insurance company licensed under chapter 60A, 
 nonprofit health service corporation operating under chapter 
 62C, fraternal benefit society operating under chapter 64B, or 
 any other entity that establishes, operates, or maintains a 
 health benefit plan or network of health care providers where 
 the providers have entered into a contract with the entity to 
 provide health care services.  

    (b) This subdivision does not apply to a health plan 
 company with respect to coverage described in section 62A.011, 
 subdivision 3, clauses (1) to (5) and (7) to (12).  

    Subd. 5.    Fee schedule.  "Fee schedule" means the 
 total expected financial compensation paid to a health care 
 provider for providing a health care service as determined by 
 the contract between the health plan company and the provider, 
 inclusive of withhold amounts and any amount for which the 
 patient or other third party may be obligated to pay under the 
 contract.  

    HIST: 2004 c 246 s 3 

     62Q.734 Exemption. 

    Sections 62Q.735 to 62Q.739, and 62Q.74 do not apply to 
 health plan companies whose annual Minnesota health premium 
 revenues are less than three percent of the total annual 
 Minnesota health premium revenues, as measured by the assessment 
 base of the Minnesota Comprehensive Health Association.  For 
 purposes of this percentage calculation, a health plan company's 
 premiums include the Minnesota health premium revenues of its 
 affiliates.  

    HIST: 2004 c 246 s 4 

     62Q.735 Provider contracting procedures. 

    Subdivision 1.    Contract disclosure.  (a) Before 
 requiring a health care provider to sign a contract, a health 
 plan company shall give to the provider a complete copy of the 
 proposed contract, including:  

    (1) all attachments and exhibits; 

    (2) operating manuals; 

    (3) a general description of the health plan company's 
 health service coding guidelines and requirement for procedures 
 and diagnoses with modifiers, and multiple procedures; and 

    (4) all guidelines and treatment parameters incorporated or 
 referenced in the contract.  

    (b) The health plan company shall make available to the 
 provider the fee schedule or a method or process that allows the 
 provider to determine the fee schedule for each health care 
 service to be provided under the contract.  

    (c) Notwithstanding paragraph (b), a health plan company 
 that is a dental plan organization, as defined in section 
 62Q.76, shall disclose information related to the individual 
 contracted provider's expected reimbursement from the dental 
 plan organization.  Nothing in this section requires a dental 
 plan organization to disclose the plan's aggregate maximum 
 allowable fee table used to determine other providers' fees.  
 The contracted provider must not release this information in any 
 way that would violate any state or federal antitrust law.  

    Subd. 2.    Proposed amendments.  (a) Any amendment or 
 change in the terms of an existing contract between a health 
 plan company and a provider must be disclosed to the provider at 
 least 45 days prior to the effective date of the proposed 
 change, with the exception of amendments required of the health 
 plan company by law or governmental regulatory authority, when 
 notice shall be given to the provider when the requirement is 
 made known to the health plan company.  

    (b) Any amendment or change in the contract that alters the 
 fee schedule or materially alters the written contractual 
 policies and procedures governing the relationship between the 
 provider and the health plan company must be disclosed to the 
 provider not less than 45 days before the effective date of the 
 proposed change and the provider must have the opportunity to 
 terminate the contract before the amendment or change is deemed 
 to be in effect.  

    (c) By mutual consent, evidenced in writing in amendments 
 separate from the base contract and not contingent on 
 participation, the parties may waive the disclosure requirements 
 under paragraphs (a) and (b).  

    (d) Notwithstanding paragraphs (a) and (b), the effective 
 date of contract termination shall comply with the terms of the 
 contract when a provider terminates a contract.  

    Subd. 3.    Hospital contract amendment disclosure.  (a) 
 Any amendment or change in the terms of an existing contract 
 between a network organization and a hospital, ambulatory 
 surgical center, or freestanding emergency room must be 
 disclosed to that provider. 

    (b) Any amendment or change in the contract that alters the 
 financial reimbursement or alters the written contractual 
 policies and procedures governing the relationship between the 
 hospital, ambulatory surgical center, or freestanding emergency 
 room and the network organization must be disclosed to that 
 provider before the amendment or change is deemed to be in 
 effect. 

    (c) For purposes of this subdivision, "network organization"
 means a preferred provider organization, as defined in section 
 145.61, subdivision 4c; a managed care organization, as defined 
 in section 62Q.01, subdivision 5; or other entity that uses or 
 consists of a network of health care providers. 

    HIST: 2004 c 246 s 5 

*   NOTE:  This section, as added by Laws 2004, chapter 246, 
*section 5, is effective for provider contracts issued, renewed, 
*or amended on or after July 1, 2006.  Laws 2004, chapter 246, 
*section 12.

     62Q.736 Payment rates. 

    A contract between a health plan company and a provider 
 shall comply with section 62A.64.  

    HIST: 2004 c 246 s 6 

     62Q.737 Service code changes. 

    (a) For purposes of this section, "service code" means 
 current procedural terminology (CPT), current dental terminology 
 (CDT), ICD-CM, diagnosis-related groups (DRGs), or other coding 
 system. 

    (b) The health plan company shall determine the manner in 
 which it adjudicates claims.  The provider may request a 
 description of the general coding guidelines applicable to the 
 health care services the provider is reasonably expected to 
 render pursuant to the contract.  The health plan company or its 
 designee shall provide the coding guidelines not later than 30 
 days after the date the health plan receives the request.  The 
 health plan company shall provide notice of material changes to 
 the coding guidelines not later than 45 days prior to the date 
 the changes take effect and shall not make retroactive revision 
 to the coding guidelines, but may issue new guidelines.  A 
 provider who receives information under this section may use or 
 disclose the information only for the purpose of practice 
 management, billing activities, or other business operations and 
 may not disclose the information to third parties without the 
 consent of the health plan company.  

    (c) The health plan company may correct an error in a 
 submitted claim that prevents the claim from being processed, 
 provided that the health plan company:  

    (1) notifies the provider of the change and reason for the 
 change according to federal Health Insurance Portability and 
 Accountability Act (HIPAA) transaction standards; and 

    (2) offers the provider the opportunity to appeal any 
 changes.  

    (d) Nothing in this section shall be interpreted to require 
 a health plan company to violate copyright or other law by 
 disclosing proprietary licensed software.  In addition to the 
 above, the health plan company shall, upon request of a 
 contracted provider, disclose the name, edition, and model 
 version of the software that the health plan company uses to 
 determine bundling and unbundling of claims.  

    (e) This section does not apply to government programs, 
 including state public programs, Medicare, and Medicare-related 
 coverage.  

    HIST: 2004 c 246 s 7 

*   NOTE:  This section, as added by Laws 2004, chapter 246, 
*section 7, is effective for provider contracts issued, renewed, 
*or amended on or after July 1, 2006.  Laws 2004, chapter 246, 
*section 12.

     62Q.739 Unilateral terms prohibited. 

    (a) A contract between a health plan company and a health 
 care provider shall not contain or require unilateral terms 
 regarding indemnification or arbitration.  Notwithstanding any 
 prohibitions in this section, a contract between a health plan 
 company and a health care provider may be unilaterally 
 terminated by either party in accordance with the terms of the 
 contract. 

    (b) A health plan company may not terminate or fail to 
 renew a health care provider's contract without cause unless the 
 company has given the provider a written notice of the 
 termination or nonrenewal 120 days before the effective date. 

    HIST: 2004 c 246 s 8 

     62Q.74 Network shadow contracting. 

    Subdivision 1.    Definitions.  (a) For purposes of this 
 section, "category of coverage" means one of the following types 
 of health-related coverage: 

    (1) health; 

    (2) no-fault automobile medical benefits; or 

    (3) workers' compensation medical benefits. 

    (b) "Health care provider" or "provider" means a physician, 
 chiropractor, dentist, podiatrist, hospital, ambulatory surgical 
 center, freestanding emergency room, or other provider, as 
 defined in section 62J.03. 

    Subd. 2.    Provider consent required.  (a) No health 
 plan company shall require a health care provider to participate 
 in a network under a category of coverage that differs from the 
 category or categories of coverage to which the existing 
 contract between the health plan company and the provider 
 applies, without the affirmative consent of the provider 
 obtained under subdivision 3.  

    (b) No health plan company shall require, as a condition of 
 participation in any health plan, product, or other arrangement, 
 the provider to participate in a new or different health plan, 
 product, or other arrangement within a category of coverage that 
 results in a different underlying financial reimbursement 
 methodology without the affirmative consent of the provider 
 obtained under subdivision 3.  This paragraph does not apply to 
 participation in health plan products or other arrangements that 
 provide health care services to government programs, including 
 state public programs, Medicare, and Medicare-related coverage. 

    (c) Compliance with this section may not be waived in a 
 contract or otherwise. 

    Subd. 3.    Consent procedure.  (a) The health plan 
 company, if it wishes to apply an existing contract with a 
 provider to a different category of coverage or health plan, 
 product, or other arrangement within a category of coverage that 
 results in a different underlying financial reimbursement 
 methodology, shall first notify the provider in writing.  The 
 written notice must include at least the following: 

    (1) the health plan company's name, address, and telephone 
 number, and the name of the specific network, if it differs from 
 that of the health plan company; 

    (2) a description of the proposed new category of coverage 
 or health plan, product, or other arrangement within a category 
 of coverage; 

    (3) the names of all payers expected by the health plan 
 company to use the network for the new category of coverage or 
 health plan, product, or other arrangement within a category of 
 coverage; 

    (4) the approximate number of current enrollees of the 
 health plan company in that category of coverage or health plan, 
 product, or other arrangement within a category of coverage 
 within the provider's geographical area; 

    (5) a disclosure of all contract terms of the proposed new 
 category of coverage or health plan, product, or other 
 arrangement within a category of coverage, including the 
 discount or reduced fees, care guidelines, utilization review 
 criteria, prior notification process, prior authorization 
 process, and dispute resolution process; 

    (6) a form for the provider's convenience in accepting or 
 declining participation in the proposed new category of coverage 
 or health plan, product, or other arrangement within a category 
 of coverage, provided that the provider need not use that form 
 in responding; and 

    (7) a statement informing the provider of the provisions of 
 paragraph (b). 

    (b) Unless the provider has affirmatively agreed to 
 participate within 60 days after the postmark date of the 
 notice, the provider is deemed to have not accepted the proposed 
 new category of coverage or health plan, product, or other 
 arrangement within a category of coverage that results in a 
 different underlying financial reimbursement methodology. 

    Subd. 4.    Contract termination restricted.  A health 
 plan company must not terminate an existing contract with a 
 provider, or fail to honor the contract in good faith, based 
 solely on the provider's decision not to accept a proposed new 
 category of coverage or health plan, product, or other 
 arrangement within a category of coverage that results in a 
 different underlying financial reimbursement methodology.  The 
 most recent agreed-upon contractual obligations remain in force 
 until the existing contract's renewal or termination date. 

    Subd. 5.    Remedy.  If a health plan company violates 
 this section by reimbursing a provider as if the provider had 
 agreed under this section to participate in the network under a 
 category of coverage or health plan, product, or other 
 arrangement within a category of coverage that results in a 
 different underlying financial reimbursement methodology to 
 which the provider has not agreed, the provider has a cause of 
 action against the health plan company to recover two times the 
 difference between the reasonable charges for claims affected by 
 the violation and the amounts actually paid to the provider.  
 The provider is also entitled to recover costs, disbursements, 
 and reasonable attorney fees. 

    Subd. 6.    Benefit design changes.  For purposes of 
 this section, "different underlying financial reimbursement 
 methodology" does not include health plan benefit design 
 changes, including, but not limited to, changes in co-payment or 
 deductible amounts or other changes in member cost-sharing 
 requirements. 

    HIST: 1999 c 94 s 1; 2000 c 322 s 1; 2001 c 170 s 4,5; 2004 c 
 246 s 9 

*   NOTE:  The amendment to this section by Laws 2004, chapter 
*246, section 9, is effective for provider contracts issued, 
*renewed, or amended on or after July 1, 2006.  Laws 2004, 
*chapter 246, section 12.

     62Q.745 Provider contract amendment disclosure. 

    (a) Any amendment or change in the terms of an existing 
 contract between a network organization and a health care 
 provider must be disclosed to the provider. 

    (b) Any amendment or change in the contract that alters the 
 financial reimbursement or alters the written contractual 
 policies and procedures governing the relationship between the 
 provider and the network organization must be disclosed to the 
 provider before the amendment or change is deemed to be in 
 effect. 

    (c) For purposes of this section, "network organization" 
 and "health care provider" or "provider" have the meanings given 
 in section 62Q.74. 

    HIST: 2001 c 170 s 6 

*   NOTE:  This section is repealed by Laws 2004, chapter 246, section 
*11, effective for provider contracts issued, renewed, or amended on or 
*after July 1, 2006.  Laws 2004, chapter 246, section 12.

     62Q.746 Access to certain information regarding 
  providers. 

    Upon request of the commissioner, a health plan company 
 licensed under chapters 62C and 62D must provide the following 
 information: 

    (1) a detailed description of the health plan company's 
 methods and procedures, standards, qualifications, criteria, and 
 credentialing requirements for designating the providers who are 
 eligible to participate in the health plan company's provider 
 network, including any limitations on the numbers of providers 
 to be included in the network; 

    (2) the number of full-time equivalent physicians, by 
 specialty, nonphysician providers, and allied health providers 
 used to provide services; and 

    (3) summary data that is broken down by type of provider, 
 reflecting actual utilization of network and non-network 
 practitioners and allied professionals by enrollees of the 
 health plan company. 

    HIST: 2001 c 170 s 7 

     62Q.75 Prompt payment required. 

    Subdivision 1.    Definitions.  (a) For purposes of this 
 section, the following terms have the meanings given to them. 

    (b) "Clean claim" means a claim that has no defect or 
 impropriety, including any lack of any required substantiating 
 documentation, including, but not limited to, coordination of 
 benefits information, or particular circumstance requiring 
 special treatment that prevents timely payment from being made 
 on a claim under this section.  Nothing in this section alters 
 an enrollee's obligation to disclose information as required by 
 law.  

    (c) "Third-party administrator" means a third-party 
 administrator or other entity subject to section 60A.23, 
 subdivision 8, and Minnesota Rules, chapter 2767. 

    Subd. 2.    Claims payments.  (a) This section applies 
 to clean claims submitted to a health plan company or 
 third-party administrator for services provided by any: 

    (1) health care provider, as defined in section 62Q.74, but 
 does not include a provider licensed under chapter 151; 

    (2) home health care provider, as defined in section 
 144A.43, subdivision 4; or 

    (3) health care facility. 

 All health plan companies and third-party administrators must 
 pay or deny claims that are clean claims within 30 calendar days 
 after the date upon which the health plan company or third-party 
 administrator received the claim. 

    (b) The health plan company or third-party administrator 
 shall, upon request, make available to the provider information 
 about the status of a claim submitted by the provider consistent 
 with section 62J.581. 

    (c) If a health plan company or third-party administrator 
 does not pay or deny a clean claim within the period provided in 
 paragraph (a), the health plan company or third-party 
 administrator must pay interest on the claim for the period 
 beginning on the day after the required payment date specified 
 in paragraph (a) and ending on the date on which the health plan 
 company or third-party administrator makes the payment or denies 
 the claim.  In any payment, the health plan company or 
 third-party administrator must itemize any interest payment 
 being made separately from other payments being made for 
 services provided.  The health plan company or third-party 
 administrator shall not require the health care provider to bill 
 the health plan company or third-party administrator for the 
 interest required under this section before any interest payment 
 is made.  Interest payments must be made to the health care 
 provider no less frequently than quarterly. 

    (d) The rate of interest paid by a health plan company or 
 third-party administrator under this subdivision shall be 1.5 
 percent per month or any part of a month. 

    (e) A health plan company or third-party administrator is 
 not required to make an interest payment on a claim for which 
 payment has been delayed for purposes of reviewing potentially 
 fraudulent or abusive billing practices. 

    (f) The commissioner may assess a financial administrative 
 penalty against a health plan company for violation of this 
 subdivision when there is a pattern of abuse that demonstrates a 
 lack of good faith effort and a systematic failure of the health 
 plan company to comply with this subdivision. 

    Subd. 3.    Claims filing.  Unless otherwise provided by 
 contract, by section 16A.124, subdivision 4a, or by federal law, 
 the health care providers and facilities specified in 
 subdivision 2 must submit their charges to a health plan company 
 or third-party administrator within six months from the date of 
 service or the date the health care provider knew or was 
 informed of the correct name and address of the responsible 
 health plan company or third-party administrator, whichever is 
 later.  A health care provider or facility that does not make an 
 initial submission of charges within the six-month period shall 
 not be reimbursed for the charge and may not collect the charge 
 from the recipient of the service or any other payer.  The 
 six-month submission requirement may be extended to 12 months in 
 cases where a health care provider or facility specified in 
 subdivision 2 has determined and can substantiate that it has 
 experienced a significant disruption to normal operations that 
 materially affects the ability to conduct business in a normal 
 manner and to submit claims on a timely basis.  This subdivision 
 also applies to all health care providers and facilities that 
 submit charges to workers' compensation payers for treatment of 
 a workers' compensation injury compensable under chapter 176, or 
 to reparation obligors for treatment of an injury compensable 
 under chapter 65B. 

    HIST: 2000 c 349 s 1; 2004 c 246 s 10; 2005 c 77 s 4 

DENTAL PLANS

     62Q.76 Definitions. 

    Subdivision 1.    Applicability.  For purposes of 
 sections 62Q.76 to 62Q.79, the terms defined in this section 
 have the meanings given them. 

    Subd. 2.    Dental care services.  "Dental care services"
 means services performed by a licensed dentist or any person 
 working under the dentist's supervision as permitted under 
 chapter 150A, which an enrollee might reasonably require to 
 maintain good dental health, including preventive services, 
 diagnostic services, emergency dental care, and restorative 
 services. 

    Subd. 3.    Dental plan.  "Dental plan" means a policy, 
 contract, or certificate offered by a dental organization for 
 the coverage of dental care services.  Dental plan means 
 individual or group coverage. 

    Subd. 4.    Dentist.  "Dentist" means a person licensed 
 to practice dentistry under chapter 150A. 

    Subd. 5.    Emergency dental care.  "Emergency dental 
 care" means the provision of dental care services for a sudden, 
 acute dental condition that would lead a prudent layperson to 
 reasonably expect that the absence of immediate care would 
 result in serious impairment to the dentition or would place the 
 person's oral health in serious jeopardy. 

    Subd. 6.    Enrollee.  "Enrollee" means an individual 
 covered by a dental organization and includes an insured, 
 policyholder, subscriber, contract holder, member, covered 
 person, or certificate holder. 

    Subd. 7.    Dental organization.  "Dental organization" 
 means a health insurer licensed under chapter 60A; a health 
 service plan corporation licensed under chapter 62C; a health 
 maintenance organization licensed under chapter 62D; a community 
 integrated service network licensed under chapter 62N; or a 
 third party administrator that: 

    (i) provides, either directly or through contracts with 
 providers or other persons, dental care services; 

    (ii) arranges for the provision of these services to 
 enrollees on the basis of a fixed, prepaid sum without regard to 
 the frequency or extent of services furnished to any particular 
 enrollee; or 

    (iii) administers dental plans. 

    HIST: 2000 c 410 s 1 

     62Q.77 Terms of coverage disclosure. 

    A dental organization shall make available to an enrollee, 
 upon request, a clear and concise description of the following 
 terms of coverage: 

    (1) the dental care services and other benefits to which 
 the enrollee is entitled under the dental plan; 

    (2) any exclusions or limitation on the services, kind of 
 services, benefits, or kind of benefits to be provided, 
 including any deductible or co-payment features and any 
 requirements for referrals to specialists; 

    (3) a description as to how services, including emergency 
 dental care and out-of-area service, may be obtained; 

    (4) a general description of payment and co-payment amounts, 
 if any, for dental care services, which the enrollee is 
 obligated to pay; and 

    (5) a telephone number by which the enrollee may obtain 
 additional information regarding coverage. 

    HIST: 2000 c 410 s 2 

     62Q.78 Dental benefit plan requirements. 

    Subdivision 1.    Utilization profiling.  (a) A dental 
 organization that uses utilization profiling as a method of 
 differentiating provider reimbursement or as a requirement for 
 continued participation in the organization's provider network 
 shall, upon request, make available to participating dentists 
 the following information: 

    (1) a description of the methodology used in profiling so 
 that dentists can clearly understand why and how they are 
 affected; and 

    (2)(i) a list of the codes measured; (ii) a dentist's 
 personal frequency data within each code so that the accuracy of 
 the data can be verified; and (iii) an individual dentist's 
 representation of scoring compared to classification points and 
 how the dentist compares with peers in each category including 
 the cutoff point of the score impacting qualification in order 
 to inform the dentist about how the dentist may qualify or 
 retain qualification for differentiated provider reimbursement 
 or continued participation in the dental organization's provider 
 network. 

    (b) A dental organization that uses utilization profiling 
 as a method of differentiating provider reimbursement or as a 
 requirement for continued participation in the organization's 
 provider network shall, upon request, provide a clear and 
 concise description of the methodology of the utilization 
 profiling on dental benefits to group purchasers and enrollees. 

    (c) A dental organization shall not be considered to be 
 engaging in the practice of dentistry pursuant to chapter 150A, 
 to the extent it releases utilization profiling information as 
 required by sections 62Q.76 to 62Q.79. 

    Subd. 2.    Reimbursement codes.  (a) Unless the federal 
 government requires the use of other procedural codes, for all 
 dental care services in which a procedural code is used by the 
 dental organization to determine coverage or reimbursement, the 
 organization must use the most recent American Dental 
 Association current dental terminology code that is available, 
 within a year of its release.  Current dental terminology codes 
 must be used as specifically defined, must be listed separately, 
 and must not be altered or changed by either the dentist or the 
 dental organization. 

    (b) Enrollee benefits must be determined on the basis of 
 individual codes subject to provider and group contracts. 

    (c) This subdivision does not prohibit or restrict dental 
 organizations from setting reimbursement and pricing with 
 groups, purchasers, and participating providers or addressing 
 issues of fraud or errors in claims submissions. 

    Subd. 3.    Treatment options.  No contractual provision 
 between a dental organization and a dentist shall in any way 
 prohibit or limit a dentist from discussing all clinical options 
 for treatment with the patient. 

    HIST: 2000 c 410 s 3 

     62Q.79 Limitations. 

    (a) The provisions contained in section 62Q.77 shall not 
 require a dental organization to disclose information which the 
 dental organization is already obligated to disclose under 
 applicable Minnesota law governing the operation of the dental 
 organization. 

    (b) Any information a dental organization is required to 
 disclose or communicate under section 62Q.77 to its subscribers, 
 enrollees, participating providers, contracting groups, or 
 dentists may be accomplished by electronic communication 
 including, but not limited to, e-mail, the Internet, Web sites, 
 and employer electronic bulletin boards. 

    HIST: 2000 c 410 s 4