1.1                          A bill for an act 
  1.2             relating to health; providing cost containment goals 
  1.3             for health care; extending the repealer of the 
  1.4             prohibition on exclusive relationships; amending 
  1.5             Minnesota Statutes 1994, sections 62J.04, subdivision 
  1.6             1; and 62Q.09, subdivision 5; Minnesota Statutes 1995 
  1.7             Supplement, sections 62J.04, subdivisions 1a and 3; 
  1.8             62J.041; and 62J.042, subdivisions 2, 3, and 4. 
  1.9   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.10     Section 1.  Minnesota Statutes 1994, section 62J.04, 
  1.11  subdivision 1, is amended to read: 
  1.12     Subdivision 1.  [LIMITS ON THE RATE OF GROWTH COST 
  1.13  CONTAINMENT GOALS.] (a) The commissioner of health shall set 
  1.14  annual limits on the rate of growth of cost containment goals 
  1.15  for public and private spending on health care services for 
  1.16  Minnesota residents, as provided in paragraph (b).  The limits 
  1.17  on growth cost containment goals must be set at levels the 
  1.18  commissioner determines to be realistic and achievable but that 
  1.19  will reduce the rate of growth in health care spending by at 
  1.20  least ten percent per year for the next five years.  The 
  1.21  commissioner shall set limits on growth cost containment goals 
  1.22  based on available data on spending and growth trends, including 
  1.23  data from group purchasers, national data on public and private 
  1.24  sector health care spending and cost trends, and trend 
  1.25  information from other states. 
  1.26     (b) The commissioner shall set the following annual limits 
  1.27  on the rate of growth of cost containment goals for public and 
  2.1   private spending on health care services for Minnesota residents:
  2.2      (1) for calendar year 1994, the rate of growth cost 
  2.3   containment goal must not exceed the change in the regional 
  2.4   consumer price index for urban consumers for calendar year 1993 
  2.5   plus 6.5 percentage points; 
  2.6      (2) for calendar year 1995, the rate of growth cost 
  2.7   containment goal must not exceed the change in the regional 
  2.8   consumer price index for urban consumers for calendar year 1994 
  2.9   plus 5.3 percentage points; 
  2.10     (3) for calendar year 1996, the rate of growth cost 
  2.11  containment goal must not exceed the change in the regional 
  2.12  consumer price index for urban consumers for calendar year 1995 
  2.13  plus 4.3 percentage points; 
  2.14     (4) for calendar year 1997, the rate of growth cost 
  2.15  containment goal must not exceed the change in the regional 
  2.16  consumer price index for urban consumers for calendar year 1996 
  2.17  plus 3.4 percentage points; and 
  2.18     (5) for calendar year 1998, the rate of growth cost 
  2.19  containment goal must not exceed the change in the regional 
  2.20  consumer price index for urban consumers for calendar year 1997 
  2.21  plus 2.6 percentage points. 
  2.22     The commissioner shall adjust the growth limit cost 
  2.23  containment goal set for calendar year 1995 to recover savings 
  2.24  in health care spending required for the period July 1, 1993, to 
  2.25  December 31, 1993. 
  2.26     (c) The commissioner shall publish: 
  2.27     (1) the projected limits cost containment goal in the State 
  2.28  Register by April 15 of the year immediately preceding the year 
  2.29  in which the limit cost containment goal will be effective 
  2.30  except for the year 1993, in which the limit cost containment 
  2.31  goal shall be published by July 1, 1993; 
  2.32     (2) the quarterly change in the regional consumer price 
  2.33  index for urban consumers; and 
  2.34     (3) the health care financing administration forecast for 
  2.35  total growth in the national health care expenditures.  In 
  2.36  setting an annual limit the cost containment goals, the 
  3.1   commissioner is exempt from the rulemaking requirements of 
  3.2   chapter 14.  The commissioner's decision on an annual limit the 
  3.3   cost containment goals is not appealable. 
  3.4      Sec. 2.  Minnesota Statutes 1995 Supplement, section 
  3.5   62J.04, subdivision 1a, is amended to read: 
  3.6      Subd. 1a.  [ADJUSTED GROWTH LIMITS AND ENFORCEMENT COST 
  3.7   CONTAINMENT GOALS.] (a) The commissioner shall publish the final 
  3.8   adjusted growth limit cost containment goal in the State 
  3.9   Register by January 31 of the year that the expenditure limit 
  3.10  cost containment goal is to be in effect.  The adjusted limit 
  3.11  cost containment goal must reflect the actual regional consumer 
  3.12  price index for urban consumers for the previous calendar year, 
  3.13  and may deviate from the previously published projected growth 
  3.14  limits cost containment goal to reflect differences between the 
  3.15  actual regional consumer price index for urban consumers and the 
  3.16  projected Consumer Price Index for urban consumers.  The 
  3.17  commissioner shall report to the legislature by February 15 of 
  3.18  each year on the implementation of the growth limits cost 
  3.19  containment goal.  This annual report shall describe the 
  3.20  differences between the projected increase in health care 
  3.21  expenditures, the actual expenditures based on data collected, 
  3.22  and the impact and validity of growth limits cost containment 
  3.23  goals within the overall health care reform strategy. 
  3.24     (b) The commissioner, in consultation with the Minnesota 
  3.25  health care commission, shall research and include in the annual 
  3.26  report required in paragraph (a) for 1996, recommendations 
  3.27  regarding the implementation of growth limits for health plan 
  3.28  companies and providers.  The commissioner shall: 
  3.29     (1) consider both spending and revenue approaches and 
  3.30  report on the implementation of the interim limits as defined in 
  3.31  sections 62J.041 and 62J.042; 
  3.32     (2) make recommendations regarding the enforcement 
  3.33  mechanism and consider mechanisms to adjust future growth limits 
  3.34  as well as mechanisms to establish financial penalties for 
  3.35  noncompliance; 
  3.36     (3) address the feasibility of systemwide limits imposed on 
  4.1   all integrated service networks; and 
  4.2      (4) make recommendations on the most effective way to 
  4.3   implement growth limits on the fee-for-service system in the 
  4.4   absence of a regulated all-payer system. 
  4.5      (c) The commissioner shall enforce limits on growth in 
  4.6   spending for health plan companies and revenues for providers.  
  4.7   If the commissioner determines that artificial inflation or 
  4.8   padding of costs or prices has occurred in anticipation of the 
  4.9   implementation of growth limits, the commissioner may adjust the 
  4.10  base year spending totals or growth limits or take other action 
  4.11  to reverse the effect of the artificial inflation or padding. 
  4.12     (d) The commissioner shall impose and enforce overall 
  4.13  limits on growth in spending for health plan companies, with 
  4.14  adjustments for changes in enrollment, benefits, severity, and 
  4.15  risks.  If a health plan company exceeds the growth limits, the 
  4.16  commissioner may impose financial penalties up to the amount 
  4.17  exceeding the applicable growth limit. 
  4.18     Sec. 3.  Minnesota Statutes 1995 Supplement, section 
  4.19  62J.04, subdivision 3, is amended to read: 
  4.20     Subd. 3.  [COST CONTAINMENT DUTIES.] After obtaining the 
  4.21  advice and recommendations of the Minnesota health care 
  4.22  commission, the commissioner shall: 
  4.23     (1) establish statewide and regional limits on growth in 
  4.24  cost containment goals for total health care spending under this 
  4.25  section, and collect data as described in sections 62J.37 to 
  4.26  62J.41 to monitor statewide compliance with the spending limits, 
  4.27  and take action to achieve compliance to the extent authorized 
  4.28  by the legislature achievement of the cost containment goals; 
  4.29     (2) divide the state into no fewer than four regions, with 
  4.30  one of those regions being the Minneapolis/St. Paul metropolitan 
  4.31  statistical area but excluding Chisago, Isanti, Wright, and 
  4.32  Sherburne counties, for purposes of fostering the development of 
  4.33  regional health planning and coordination of health care 
  4.34  delivery among regional health care systems and working to 
  4.35  achieve spending limits the cost containment goals; 
  4.36     (3) provide technical assistance to regional coordinating 
  5.1   boards; 
  5.2      (4) monitor the quality of health care throughout the state 
  5.3   and take action as necessary to ensure an appropriate level of 
  5.4   quality; 
  5.5      (5) issue recommendations regarding uniform billing forms, 
  5.6   uniform electronic billing procedures and data interchanges, 
  5.7   patient identification cards, and other uniform claims and 
  5.8   administrative procedures for health care providers and private 
  5.9   and public sector payers.  In developing the recommendations, 
  5.10  the commissioner shall review the work of the work group on 
  5.11  electronic data interchange (WEDI) and the American National 
  5.12  Standards Institute (ANSI) at the national level, and the work 
  5.13  being done at the state and local level.  The commissioner may 
  5.14  adopt rules requiring the use of the Uniform Bill 82/92 form, 
  5.15  the National Council of Prescription Drug Providers (NCPDP) 3.2 
  5.16  electronic version, the Health Care Financing Administration 
  5.17  1500 form, or other standardized forms or procedures; 
  5.18     (6) undertake health planning responsibilities as provided 
  5.19  in section 62J.15; 
  5.20     (7) authorize, fund, or promote research and 
  5.21  experimentation on new technologies and health care procedures; 
  5.22     (8) within the limits of appropriations for these purposes, 
  5.23  administer or contract for statewide consumer education and 
  5.24  wellness programs that will improve the health of Minnesotans 
  5.25  and increase individual responsibility relating to personal 
  5.26  health and the delivery of health care services, undertake 
  5.27  prevention programs including initiatives to improve birth 
  5.28  outcomes, expand childhood immunization efforts, and provide 
  5.29  start-up grants for worksite wellness programs; and 
  5.30     (9) undertake other activities to monitor and oversee the 
  5.31  delivery of health care services in Minnesota with the goal of 
  5.32  improving affordability, quality, and accessibility of health 
  5.33  care for all Minnesotans; and 
  5.34     (10) make the cost containment goal data available to the 
  5.35  public in a consumer-oriented manner. 
  5.36     Sec. 4.  Minnesota Statutes 1995 Supplement, section 
  6.1   62J.041, is amended to read: 
  6.2      62J.041 [INTERIM HEALTH PLAN COMPANY EXPENDITURE LIMITS 
  6.3   COST CONTAINMENT GOALS.] 
  6.4      Subdivision 1.  [DEFINITIONS.] (a) For purposes of this 
  6.5   section, the following definitions apply. 
  6.6      (b) "Health plan company" has the definition provided in 
  6.7   section 62Q.01. 
  6.8      (c) "Total expenditures" means incurred claims or 
  6.9   expenditures on health care services, administrative expenses, 
  6.10  charitable contributions, and all other payments made by health 
  6.11  plan companies out of premium revenues. 
  6.12     (d) "Net expenditures" means total expenditures minus 
  6.13  exempted taxes and assessments and payments or allocations made 
  6.14  to establish or maintain reserves.  
  6.15     (e) "Exempted taxes and assessments" means direct payments 
  6.16  for taxes to government agencies, contributions to the Minnesota 
  6.17  comprehensive health association, the medical assistance 
  6.18  provider's surcharge under section 256.9657, the MinnesotaCare 
  6.19  provider tax under section 295.52, assessments by the health 
  6.20  coverage reinsurance association, assessments by the Minnesota 
  6.21  life and health insurance guaranty association, assessments by 
  6.22  the Minnesota risk adjustment association, and any new 
  6.23  assessments imposed by federal or state law. 
  6.24     (f) "Consumer cost-sharing or subscriber liability" means 
  6.25  enrollee coinsurance, copayment, deductible payments, and 
  6.26  amounts in excess of benefit plan maximums. 
  6.27     Subd. 2.  [ESTABLISHMENT.] The commissioner of health shall 
  6.28  establish limits on cost containment goals for the increase in 
  6.29  net expenditures by each health carrier plan company for 
  6.30  calendar years 1994, 1995, 1996, and 1997.  The limits cost 
  6.31  containment goals must be the same as the annual rate of growth 
  6.32  in cost containment goals for health care spending established 
  6.33  under section 62J.04, subdivision 1, paragraph (b).  Health plan 
  6.34  companies that are affiliates may elect to meet one 
  6.35  combined expenditure limit cost containment goal. 
  6.36     Subd. 3.  [DETERMINATION OF EXPENDITURES.] Health plan 
  7.1   companies shall submit to the commissioner of health, by April 
  7.2   1, 1994, for calendar year 1993; April 1, 1995, for calendar 
  7.3   year 1994; April 1, 1996, for calendar year 1995; April 1, 1997, 
  7.4   for calendar year 1996; and April 1, 1998, for calendar year 
  7.5   1997 all information the commissioner determines to be necessary 
  7.6   to implement and enforce this section.  The information must be 
  7.7   submitted in the form specified by the commissioner.  The 
  7.8   information must include, but is not limited to, expenditures 
  7.9   per member per month or cost per employee per month, and 
  7.10  detailed information on revenues and reserves.  The 
  7.11  commissioner, to the extent possible, shall coordinate the 
  7.12  submittal of the information required under this section with 
  7.13  the submittal of the financial data required under chapter 62J, 
  7.14  to minimize the administrative burden on health plan companies.  
  7.15  The commissioner may adjust final expenditure figures for 
  7.16  demographic changes, risk selection, changes in basic benefits, 
  7.17  and legislative initiatives that materially change health care 
  7.18  costs, as long as these adjustments are consistent with the 
  7.19  methodology submitted by the health plan company to the 
  7.20  commissioner, and approved by the commissioner as actuarially 
  7.21  justified.  The methodology to be used for adjustments and the 
  7.22  election to meet one expenditure limit cost containment goal for 
  7.23  affiliated health plan companies must be submitted to the 
  7.24  commissioner by September 1, 1994.  Community integrated service 
  7.25  networks may submit the information with their application for 
  7.26  licensure.  The commissioner shall also accept changes to 
  7.27  methodologies already submitted.  The adjustment methodology 
  7.28  submitted and approved by the commissioner must apply to the 
  7.29  data submitted for calendar years 1994 and 1995.  The 
  7.30  commissioner may allow changes to accepted adjustment 
  7.31  methodologies for data submitted for calendar years 1996 and 
  7.32  1997.  Changes to the adjustment methodology must be received by 
  7.33  September 1, 1996, and must be approved by the commissioner. 
  7.34     Subd. 4.  [MONITORING OF RESERVES.] (a) The commissioners 
  7.35  of health and commerce shall monitor health plan company 
  7.36  reserves and net worth as established under chapters 60A, 62C, 
  8.1   62D, 62H, and 64B, with respect to the health plan companies 
  8.2   that each commissioner respectively regulates to ensure 
  8.3   that assess the degree to which savings resulting from the 
  8.4   establishment of expenditure limits cost containment goals are 
  8.5   passed on to consumers in the form of lower premium rates.  
  8.6      (b) Health plan companies shall fully reflect in the 
  8.7   premium rates the savings generated by the expenditure limits 
  8.8   cost containment goals.  No premium rate, currently reviewed by 
  8.9   the departments of health or commerce, may be approved for those 
  8.10  health plan companies unless the health plan company establishes 
  8.11  to the satisfaction of the commissioner of commerce or the 
  8.12  commissioner of health, as appropriate, that the proposed new 
  8.13  rate would comply with this paragraph. 
  8.14     (c) Health plan companies, except those licensed under 
  8.15  chapter 60A to sell accident and sickness insurance under 
  8.16  chapter 62A, shall annually before the end of the fourth fiscal 
  8.17  quarter provide to the commissioner of health or commerce, as 
  8.18  applicable, a projection of the level of reserves the company 
  8.19  expects to attain during each quarter of the following fiscal 
  8.20  year.  These health plan companies shall submit with required 
  8.21  quarterly financial statements a calculation of the actual 
  8.22  reserve level attained by the company at the end of each quarter 
  8.23  including identification of the sources of any significant 
  8.24  changes in the reserve level and an updated projection of the 
  8.25  level of reserves the health plan company expects to attain by 
  8.26  the end of the fiscal year.  In cases where the health plan 
  8.27  company has been given a certificate to operate a new health 
  8.28  maintenance organization under chapter 62D, or been licensed as 
  8.29  an integrated service network or community integrated service 
  8.30  network under chapter 62N, or formed an affiliation with one of 
  8.31  these organizations, the health plan company shall also submit 
  8.32  with its quarterly financial statement, total enrollment at the 
  8.33  beginning and end of the quarter and enrollment changes within 
  8.34  each service area of the new organization.  The reserve 
  8.35  calculations shall be maintained by the commissioners as trade 
  8.36  secret information, except to the extent that such information 
  9.1   is also required to be filed by another provision of state law 
  9.2   and is not treated as trade secret information under such other 
  9.3   provisions. 
  9.4      (d) Health plan companies in paragraph (c) whose reserves 
  9.5   are less than the required minimum or more than the required 
  9.6   maximum at the end of the fiscal year shall submit a plan of 
  9.7   corrective action to the commissioner of health or commerce 
  9.8   under subdivision 7. 
  9.9      (e) The commissioner of commerce, in consultation with the 
  9.10  commissioner of health, shall report to the legislature no later 
  9.11  than January 15, 1995, as to whether the concept of a reserve 
  9.12  corridor or other mechanism for purposes of monitoring reserves 
  9.13  is adaptable for use with indemnity health insurers that do 
  9.14  business in multiple states and that must comply with their 
  9.15  domiciliary state's reserves requirements. 
  9.16     Subd. 5.  [NOTICE.] The commissioner of health shall 
  9.17  publish in the State Register and make available to the public 
  9.18  by July 1, 1995, a list of all health plan companies that 
  9.19  exceeded their expenditure limit cost containment goal for the 
  9.20  1994 calendar year.  The commissioner shall publish in the State 
  9.21  Register and make available to the public by July 1, 1996, a 
  9.22  list of all health plan companies that exceeded their 
  9.23  combined expenditure limit cost containment goal for calendar 
  9.24  years 1994 and 1995.  The commissioner shall notify each health 
  9.25  plan company that the commissioner has determined that the 
  9.26  health plan company exceeded its expenditure limit cost 
  9.27  containment goal, at least 30 days before publishing the list, 
  9.28  and shall provide each health plan company with ten days to 
  9.29  provide an explanation for exceeding the expenditure limit cost 
  9.30  containment goal.  The commissioner shall review the explanation 
  9.31  and may change a determination if the commissioner determines 
  9.32  the explanation to be valid. 
  9.33     Subd. 6.  [ASSISTANCE BY THE COMMISSIONER OF COMMERCE.] The 
  9.34  commissioner of commerce shall provide assistance to the 
  9.35  commissioner of health in monitoring health plan companies 
  9.36  regulated by the commissioner of commerce.  The commissioner of 
 10.1   commerce, in consultation with the commissioner of health, shall 
 10.2   enforce compliance with expenditure limits for those health plan 
 10.3   companies. 
 10.4      Subd. 7.  [ENFORCEMENT.] (a) The commissioners of health 
 10.5   and commerce shall enforce the reserve limits referenced in 
 10.6   subdivision 4, with respect to the health plan companies that 
 10.7   each commissioner respectively regulates.  Each commissioner 
 10.8   shall require health plan companies under the commissioner's 
 10.9   jurisdiction to submit plans of corrective action when the 
 10.10  reserve requirement is not met.  The plan of correction must 
 10.11  address the following: 
 10.12     (1) actuarial assumptions used in forecasting future 
 10.13  financial results; 
 10.14     (2) trend assumptions used in setting future premiums; 
 10.15     (3) demographic, geographic, and private and public sector 
 10.16  mix of the population covered by the health plan company; 
 10.17     (4) proposed rate increases or decreases; 
 10.18     (5) growth limits applied under section 62J.04, subdivision 
 10.19  1, paragraph (b); and 
 10.20     (6) other factors deemed appropriate by the health plan 
 10.21  company or commissioner. 
 10.22  If the health plan company's reserves exceed the required 
 10.23  maximum, the plan of correction shall address how the health 
 10.24  plan company will come into compliance and set forth a timetable 
 10.25  within which compliance would be achieved.  The plan of 
 10.26  correction may propose premium refunds, credits for prior 
 10.27  premiums paid, policyholder dividends, or any combination of 
 10.28  these or other methods which will benefit enrollees and/or 
 10.29  Minnesota residents and are such that the reserve requirements 
 10.30  can reasonably be expected to be met.  The commissioner's 
 10.31  evaluation of the plan of correction must consider: 
 10.32     (1) whether implementation of the plan would provide the 
 10.33  company with an unfair advantage in the market; 
 10.34     (2) the extent to which the reserve excess was created by 
 10.35  any movement of enrolled persons to another organization formed 
 10.36  by the company; 
 11.1      (3) whether any proposed premium refund, credit, and/or 
 11.2   dividend represents an equitable allocation to policyholders 
 11.3   covered in prior periods as determined using sound actuarial 
 11.4   practice; and 
 11.5      (4) any other factors deemed appropriate by the applicable 
 11.6   commissioner. 
 11.7      (b) The plan of correction is subject to approval by the 
 11.8   commissioner of health or commerce, as applicable.  If such a 
 11.9   plan is not approved by the applicable commissioner, the 
 11.10  applicable commissioner shall enter an order stating the steps 
 11.11  that the health plan company must take to come into compliance.  
 11.12  Within 30 days of the date of such order, the health plan 
 11.13  company must file a notice of appeal with the applicable 
 11.14  commissioner or comply with the commissioner's order.  If an 
 11.15  appeal is filed, such appeal is governed by chapter 14. 
 11.16     (c) Health plan companies that exceed the expenditure 
 11.17  limits based on two-year average expenditure data (1994 and 
 11.18  1995, 1996 and 1997) shall be required by the appropriate 
 11.19  commissioner to pay back the amount exceeding the expenditure 
 11.20  limit through an assessment on the health plan company.  A 
 11.21  health plan company may appeal the commissioner's order to pay 
 11.22  back the amount exceeding the expenditure limit by mailing to 
 11.23  the commissioner a written notice of appeal within 30 days from 
 11.24  the date the commissioner's order was mailed.  The contested 
 11.25  case and judicial review provisions of chapter 14 apply to the 
 11.26  appeal.  The health plan company shall pay the amount specified 
 11.27  by the commissioner either to the commissioner or into an escrow 
 11.28  account until final resolution of the appeal.  Notwithstanding 
 11.29  sections 3.762 to 3.765, each party is responsible for its own 
 11.30  fees and expenses, including attorneys fees, for the appeal.  
 11.31  Any amount required to be paid back under this section shall be 
 11.32  deposited in the health care access fund.  The appropriate 
 11.33  commissioner may approve a different repayment method to take 
 11.34  into account the health plan company's financial condition.  
 11.35  Health plan companies shall comply with the limits but shall 
 11.36  also guarantee that their contractual obligations are met.  
 12.1   Health plan companies are prohibited from meeting spending 
 12.2   obligations by increasing subscriber liability, including 
 12.3   copayments and deductibles and amounts in excess of benefit plan 
 12.4   maximums. 
 12.5      Sec. 5.  Minnesota Statutes 1995 Supplement, section 
 12.6   62J.042, subdivision 2, is amended to read: 
 12.7      Subd. 2.  [ESTABLISHMENT.] The commissioner of health shall 
 12.8   establish limits on cost containment goals for the increase in 
 12.9   revenue for each health care provider, for calendar years 1994, 
 12.10  1995, 1996, and 1997.  The limits goals must be the same as the 
 12.11  annual rate of goals for growth in health care spending 
 12.12  established under section 62J.04, subdivision 1, paragraph (b).  
 12.13  The commissioner may adjust final revenue figures for case mix 
 12.14  complexity, payer mix, out-of-period settlements, certain taxes 
 12.15  and assessments including the MinnesotaCare provider tax and 
 12.16  provider surcharge, any new assessments imposed by federal or 
 12.17  state law, research and education costs, donations, grants, and 
 12.18  legislative initiatives that materially change health care 
 12.19  revenues, as long as these adjustments are consistent with the 
 12.20  methodology submitted by the health care provider to the 
 12.21  commissioner, and approved by the commissioner as actuarially 
 12.22  justified.  The methodology to be used for adjustments must be 
 12.23  submitted to the commissioner by September 1, 1994.  The 
 12.24  commissioner shall also accept changes to methodologies already 
 12.25  submitted.  The adjustment methodology submitted and approved by 
 12.26  the commissioner must apply to the data submitted for calendar 
 12.27  years 1994 and 1995.  The commissioner may allow changes to 
 12.28  accepted adjustment methodologies for data submitted for 
 12.29  calendar years 1996 and 1997.  Changes to the adjustment 
 12.30  methodology must be received by September 1, 1996, and must be 
 12.31  approved by the commissioner.  
 12.32     Sec. 6.  Minnesota Statutes 1995 Supplement, section 
 12.33  62J.042, subdivision 3, is amended to read: 
 12.34     Subd. 3.  [MONITORING OF REVENUE.] The commissioner of 
 12.35  health shall monitor health care provider revenue, to ensure 
 12.36  that assess the degree to which savings resulting from the 
 13.1   establishment of revenue limits cost containment goals are 
 13.2   passed on to consumers in the form of lower charges.  The 
 13.3   commissioner shall monitor hospital revenue by examining net 
 13.4   inpatient revenue per adjusted admission and net outpatient 
 13.5   revenue per outpatient visit.  The commissioner shall monitor 
 13.6   the revenue of physicians and other health care providers by 
 13.7   examining revenue per patient per year or revenue per 
 13.8   encounter.  For purposes of this section, definitions related to 
 13.9   the implementation of limits cost containment goals for 
 13.10  providers other than hospitals are included in Minnesota Rules, 
 13.11  chapter 4650, and definitions related to the implementation 
 13.12  of limits cost containment goals for hospitals are included in 
 13.13  Minnesota Rules, chapter 4651.  If this information is not 
 13.14  available, the commissioner may enforce an annual limit on the 
 13.15  rate of growth of the provider's current fees.  
 13.16     Sec. 7.  Minnesota Statutes 1995 Supplement, section 
 13.17  62J.042, subdivision 4, is amended to read: 
 13.18     Subd. 4.  [MONITORING AND ENFORCEMENT.] Health care 
 13.19  providers shall submit to the commissioner of health, in the 
 13.20  form and at the times required by the commissioner, all 
 13.21  information the commissioner determines to be necessary to 
 13.22  implement and enforce this section.  The commissioner shall 
 13.23  regularly audit all health clinics employing or contracting with 
 13.24  over 100 physicians.  The commissioner shall also audit, at 
 13.25  times and in a manner that does not interfere with delivery of 
 13.26  patient care, a sample of smaller clinics and other health care 
 13.27  providers.  Providers that exceed revenue limits based on 
 13.28  two-year average revenue data shall be required by the 
 13.29  commissioner to pay back the amount exceeding the revenue limits 
 13.30  during the following calendar year.  
 13.31     Pharmacists may adjust their revenue figures for increases 
 13.32  in drug product costs that are set by the manufacturer.  The 
 13.33  commissioner shall consult with pharmacy groups, including 
 13.34  pharmacies, wholesalers, drug manufacturers, health plans, and 
 13.35  other interested parties, to determine the methodology for 
 13.36  measuring and implementing the interim growth limits cost 
 14.1   containment goals while taking into account the adjustments for 
 14.2   drug product costs. 
 14.3      The commissioner shall monitor providers meeting the growth 
 14.4   limits cost containment goals based on their current fees on an 
 14.5   annual basis.  The fee charged for each service must be based on 
 14.6   a weighted average across 12 months and compared to the weighted 
 14.7   average for the previous 12-month period.  The percentage 
 14.8   increase in the average fee from 1993 to 1994, and from 1994 to 
 14.9   1995 is subject to the growth limits cost containment goals 
 14.10  established under section 62J.04, subdivision 1, paragraph (b).  
 14.11  The percentage increase in the average fee from 1995 to 1996, 
 14.12  and from 1996 to 1997 is subject to the change in the regional 
 14.13  consumer price index for urban consumers for the previous year 
 14.14  published in the State Register in January of the year that 
 14.15  the growth limit cost containment goal is in effect.  The 
 14.16  audit monitoring process may include a review of the provider's 
 14.17  monthly fee schedule, and a random claims analysis for the 
 14.18  provider during different parts of the year to monitor 
 14.19  variations in fees.  The commissioner shall require providers 
 14.20  that exceed growth limits, based on annual fees, to pay back 
 14.21  during the following calendar year the amount of fees received 
 14.22  exceeding the limit. 
 14.23     The commissioner shall notify each provider that has 
 14.24  exceeded its revenue or fee limit, at least 30 days before 
 14.25  taking action, and shall provide each provider with ten days to 
 14.26  provide an explanation for exceeding the revenue or fee limit.  
 14.27  The commissioner shall review the explanation and may change a 
 14.28  determination if the commissioner determines the explanation to 
 14.29  be valid. 
 14.30     The commissioner may approve a different repayment schedule 
 14.31  for a health care provider that takes into account the 
 14.32  provider's financial condition.  
 14.33     A provider may appeal the commissioner's order to pay back 
 14.34  the amount exceeding the revenue or fee limit by mailing a 
 14.35  written notice of appeal to the commissioner within 30 days 
 14.36  after the commissioner's order was mailed.  The contested case 
 15.1   and judicial review provisions of chapter 14 apply to the 
 15.2   appeal.  The provider shall pay the amount specified by the 
 15.3   commissioner either to the commissioner or into an escrow 
 15.4   account until final resolution of the appeal.  Notwithstanding 
 15.5   sections 3.762 to 3.765, each party is responsible for its own 
 15.6   fees and expenses, including attorneys fees, for the appeal.  
 15.7   Any amount required to be paid back under this section shall be 
 15.8   deposited in the health care access fund. 
 15.9      Sec. 8.  Minnesota Statutes 1994, section 62Q.09, 
 15.10  subdivision 5, is amended to read: 
 15.11     Subd. 5.  [SUNSET.] This section expires January 1, 
 15.12  1997 2000. 
 15.13     Sec. 9.  [EFFECTIVE DATE.] 
 15.14     Section 8 is effective the day following final enactment.