2006 Minnesota Statutes

CHAPTER 62Q. REQUIREMENTS FOR HEALTH PLAN COMPANIES

62Q.001 APPLICATION OF LAWS 2005, CHAPTER 56, TERMINOLOGY CHANGES.
State agencies shall use the terminology changes specified in Laws 2005, chapter 56, section
1, when printed material and signage are replaced and new printed material and signage are
obtained. State agencies do not have to replace existing printed material and signage to comply
with Laws 2005, chapter 56, sections 1 and 2. Language changes made according to Laws 2005,
chapter 56, sections 1 and 2, shall not expand or exclude eligibility to services.
History: 2005 c 56 s 3

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.3099 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."
History: 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 1 s 14; 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 1994 c 625 art 2 s 21

62Q.137 CHEMICAL DEPENDENCY TREATMENT; COVERAGE.
(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.
History: 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.
History: 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.
History: 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.
History: 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]
History: 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.
History: 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]
History: 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.
History: 1997 c 175 art 4 s 3

62Q.185 GUARANTEED RENEWABILITY; LARGE EMPLOYER GROUP.
(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.
History: 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 paragraph (d), 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.
History: 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; 2006 c 212 art 3 s 4

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.
History: 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, disabled 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.
History: 1994 c 625 art 4 s 8; 2005 c 56 s 1

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

62Q.251 [Repealed, 2006 c 255 s 77]

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.
History: 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.
History: 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 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.
History: 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.
History: 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.
History: 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.
History: 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).
History: 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.
History: 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).
History: 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.
History: 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.
History: 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.
History: 1998 c 301 s 1

62Q.527 NONFORMULARY ANTIPSYCHOTIC DRUGS; REQUIRED COVERAGE.
    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.
History: 1Sp2001 c 9 art 9 s 2; 2002 c 379 art 1 s 113

62Q.53 MENTAL HEALTH COVERAGE; 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).
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 1997 c 237 s 14

62Q.645 EFFICIENCY REPORTS AND DISTRIBUTION OF INFORMATION.
(a) The commissioner may use reports submitted by health plan companies, service
cooperatives, and the public employee insurance program created in section 43A.316 to compile
entity specific administrative efficiency reports; may make these reports available on state agency
Web sites, including minnesotahealthinfo.com; and may include information on:
(1) number of covered lives;
(2) covered services;
(3) geographic availability;
(4) whom to contact to obtain current premium rates;
(5) administrative costs, using the definition of administrative costs developed under section
62J.38;
(6) Internet links to information on the health plan, if available; and
(7) any other information about the health plan identified by the commissioner as being
useful for employers, consumers, providers, and others in evaluating health plan options.
(b) This section does not apply to a health plan company unless its annual Minnesota
premiums exceed $50,000,000 based on the most recent assessment base of the Minnesota
Comprehensive Health Association. For purposes of this determination, the premiums of a health
plan company include those of its affiliates.
History: 2006 c 255 s 34

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).
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 1999 c 239 s 39; 2000 c 474 s 2; 2001 c 215 s 27

62Q.731 EXTERNAL REVIEW OF ADVERSE DETERMINATION.
    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.
History: 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."
History: 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.
History: 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.
History: 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.
History: 2004 c 246 s 5

62Q.736 PAYMENT RATES.
A contract between a health plan company and a provider shall comply with section 62A.64.
History: 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.
History: 2004 c 246 s 7

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

62Q.745 [Repealed, 2004 c 246 s 11]

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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 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.
History: 2000 c 410 s 4

62Q.80 COMMUNITY-BASED HEALTH CARE COVERAGE PROGRAM.
    Subdivision 1. Scope. (a) A community-based health care initiative may develop and operate
a community-based health care coverage program that offers to eligible individuals and their
dependents the option of purchasing through their employer health care coverage on a fixed
prepaid basis without meeting the requirements of chapter 60A, 62A, 62C, 62D, 62Q, or 62T, or
any other law or rule that applies to entities licensed under these chapters.
(b) The initiative shall establish health outcomes to be achieved through the program and
performance measurements in order to determine whether these outcomes have been met. The
outcomes must include, but are not limited to:
(1) a reduction in uncompensated care provided by providers participating in the
community-based health network;
(2) an increase in the delivery of preventive health care services; and
(3) health improvement for enrollees with chronic health conditions through the management
of these conditions.
In establishing performance measurements, the initiative shall use measures that are consistent
with measures published by nonprofit Minnesota or national organizations that produce and
disseminate health care quality measures.
(c) Any program established under this section shall not constitute a financial liability for the
state, in that any financial risk involved in the operation or termination of the program shall be
borne by the community-based initiative and the participating health care providers.
    Subd. 2. Definitions. For purposes of this section, the following definitions apply:
(a) "Community-based" means located in or primarily relating to the community
of geographically contiguous political subdivisions, as determined by the board of a
community-based health initiative that is served by the community-based health care coverage
program.
(b) "Community-based health care coverage program" or "program" means a program
administered by a community-based health initiative that provides health care services through
provider members of a community-based health network or combination of networks to eligible
individuals and their dependents who are enrolled in the program.
(c) "Community-based health initiative" means a nonprofit corporation that is governed
by a board that has at least 80 percent of its members residing in the community and includes
representatives of the participating network providers and employers.
(d) "Community-based health network" means a contract-based network of health care
providers organized by the community-based health initiative to provide or support the delivery
of health care services to enrollees of the community-based health care coverage program on a
risk-sharing or nonrisk-sharing basis.
(e) "Dependent" means an eligible employee's spouse or unmarried child who is under
the age of 19 years.
    Subd. 3. Approval. (a) Prior to the operation of a community-based health care coverage
program, a community-based health initiative shall submit to the commissioner of health for
approval the community-based health care coverage program developed by the initiative. The
commissioner shall only approve a program that has been awarded a community access program
grant from the United States Department of Health and Human Services. The commissioner shall
ensure that the program meets the federal grant requirements and any requirements described in
this section and is actuarially sound based on a review of appropriate records and methods utilized
by the community-based health initiative in establishing premium rates for the community-based
health care coverage program.
(b) Prior to approval, the commissioner shall also ensure that:
(1) the benefits offered comply with subdivision 8 and that there are adequate numbers of
health care providers participating in the community-based health network to deliver the benefits
offered under the program;
(2) the activities of the program are limited to activities that are exempt under this section or
otherwise from regulation by the commissioner of commerce;
(3) the complaint resolution process meets the requirements of subdivision 10; and
(4) the data privacy policies and procedures comply with state and federal law.
    Subd. 4. Establishment. (a) The initiative shall establish and operate upon approval by the
commissioner of health a community-based health care coverage program. The operational
structure established by the initiative shall include, but is not limited to:
(1) establishing a process for enrolling eligible individuals and their dependents;
(2) collecting and coordinating premiums from enrollees and employers of enrollees;
(3) providing payment to participating providers;
(4) establishing a benefit set according to subdivision 8 and establishing premium rates and
cost-sharing requirements;
(5) creating incentives to encourage primary care and wellness services; and
(6) initiating disease management services, as appropriate.
(b) The payments collected under paragraph (a), clause (2), may be used to capture available
federal funds.
    Subd. 5. Qualifying employees. To be eligible for the community-based health care
coverage program, an individual must:
(1) reside in or work within the designated community-based geographic area served by the
program;
(2) be employed by a qualifying employer or be an employee's dependent;
(3) not be enrolled in or have currently available health coverage; and
(4) not be enrolled in medical assistance, general assistance medical care, MinnesotaCare, or
Medicare.
    Subd. 6. Qualifying employers. (a) To qualify for participation in the community-based
health care coverage program, an employer must:
(1) employ at least one but no more than 50 employees at the time of initial enrollment
in the program;
(2) pay its employees a median wage of $12.50 per hour or less; and
(3) not have offered employer-subsidized health coverage to its employees for at least
12 months prior to the initial enrollment in the program. For purposes of this section,
"employer-subsidized health coverage" means health care coverage for which the employer pays
at least 50 percent of the cost of coverage for the employee.
(b) To participate in the program, a qualifying employer agrees to:
(1) offer health care coverage through the program to all eligible employees and their
dependents regardless of health status;
(2) participate in the program for an initial term of at least one year;
(3) pay a percentage of the premium established by the initiative for the employee; and
(4) provide the initiative with any employee information deemed necessary by the initiative
to determine eligibility and premium payments.
    Subd. 7. Participating providers. Any health care provider participating in the
community-based health network must accept as payment in full the payment rate established
by the initiative and may not charge to or collect from an enrollee any amount in access of this
amount for any service covered under the program.
    Subd. 8. Coverage. (a) The initiative shall establish the health care benefits offered through
the community-based health care coverage program. The benefits established shall include,
at a minimum:
(1) child health supervision services up to age 18, as defined under section 62A.047; and
(2) preventive services, including:
(i) health education and wellness services;
(ii) health supervision, evaluation, and follow-up;
(iii) immunizations; and
(iv) early disease detection.
(b) Coverage of health care services offered by the program may be limited to participating
health care providers or health networks. All services covered under the program must be services
that are offered within the scope of practice of the participating health care providers.
(c) The initiative may establish cost-sharing requirements. Any co-payment or deductible
provisions established may not discriminate on the basis of age, sex, race, disability, economic
status, or length of enrollment in the program.
(d) If the initiative amends or alters the benefits offered through the program from the
initial offering, the initiative must notify the commissioner of health and all enrollees of the
benefit change.
    Subd. 9. Enrollee information. (a) The initiative must provide an individual or family
who enrolls in the program a clear and concise written statement that includes the following
information:
(1) health care services that are provided under the program;
(2) any exclusions or limitations on the health care services offered, including any
cost-sharing arrangements or prior authorization requirements;
(3) a list of where the health care services can be obtained and that all health care services
must be provided by or through a participating health care provider or community-based health
network;
(4) a description of the program's complaint resolution process, including how to submit a
complaint; how to file a complaint with the commissioner of health; and how to obtain an external
review of any adverse decisions as provided under subdivision 10;
(5) the conditions under which the program or coverage under the program may be canceled
or terminated; and
(6) a precise statement specifying that this program is not an insurance product and, as such,
is exempt from state regulation of insurance products.
(b) The commissioner of health must approve a copy of the written statement prior to the
operation of the program.
    Subd. 10. Complaint resolution process. (a) The initiative must establish a complaint
resolution process. The process must make reasonable efforts to resolve complaints and to inform
complainants in writing of the initiative's decision within 60 days of receiving the complaint. Any
decision that is adverse to the enrollee shall include a description of the right to an external review
as provided in paragraph (c) and how to exercise this right.
(b) The initiative must report any complaint that is not resolved within 60 days to the
commissioner of health.
(c) The initiative must include in the complaint resolution process the ability of an enrollee
to pursue the external review process provided under section 62Q.73 with any decision rendered
under this external review process binding on the initiative.
    Subd. 11. Data privacy. The initiative shall establish data privacy policies and procedures
for the program that comply with state and federal data privacy laws.
    Subd. 12. Limitations on enrollment. (a) The initiative may limit enrollment in the
program. If enrollment is limited, a waiting list must be established.
(b) The initiative shall not restrict or deny enrollment in the program except for nonpayment
of premiums, fraud or misrepresentation, or as otherwise permitted under this section.
(c) The initiative may require a certain percentage of participation from eligible employees
of a qualifying employer before coverage can be offered through the program.
    Subd. 13. Report. (a) The initiative shall submit quarterly status reports to the commissioner
of health on January 15, April 15, July 15, and October 15 of each year, with the first report due
January 15, 2007. The status report shall include:
(1) the financial status of the program, including the premium rates, cost per member per
month, claims paid out, premiums received, and administrative expenses;
(2) a description of the health care benefits offered and the services utilized;
(3) the number of employers participating, the number of employees and dependents covered
under the program, and the number of health care providers participating;
(4) a description of the health outcomes to be achieved by the program and a status report on
the performance measurements to be used and collected; and
(5) any other information requested by the commissioner of health or commerce or the
legislature.
(b) The initiative shall contract with an independent entity to conduct an evaluation of the
program to be submitted to the commissioners of health and commerce and the legislature by
January 15, 2009. The evaluation shall include:
(1) an analysis of the health outcomes established by the initiative and the performance
measurements to determine whether the outcomes are being achieved;
(2) an analysis of the financial status of the program, including the claims to premiums
loss ratio and utilization and cost experience;
(3) the demographics of the enrollees, including their age, gender, family income, and
the number of dependents;
(4) the number of employers and employees who have been denied access to the program
and the basis for the denial;
(5) specific analysis on enrollees who have aggregate medical claims totaling over $5,000
per year, including data on the enrollee's main diagnosis and whether all the medical claims
were covered by the program;
(6) number of enrollees referred to state public assistance programs;
(7) a comparison of employer-subsidized health coverage provided in a comparable
geographic area to the designated community-based geographic area served by the program,
including, to the extent available:
(i) the difference in the number of employers with 50 or fewer employees offering
employer-subsidized health coverage;
(ii) the difference in uncompensated care being provided in each area; and
(iii) a comparison of health care outcomes and measurements established by the initiative;
and
(8) any other information requested by the commissioner of health or commerce.
    Subd. 14. Sunset. This section expires December 31, 2011.
History: 2006 c 255 s 35