1.1                          A bill for an act 
  1.2             relating to health; providing patient protections; 
  1.3             modifying the Health Care Administrative 
  1.4             Simplification Act; modifying comprehensive health 
  1.5             insurance provisions; advancing the expiration date 
  1.6             for the consumer advisory board; requiring coverage 
  1.7             for medical clinical trials; amending Minnesota 
  1.8             Statutes 1998, sections 62D.08, by adding a 
  1.9             subdivision; 62D.17, subdivision 1; 62E.04, 
  1.10            subdivision 4; 62J.38; 62J.51, by adding subdivisions; 
  1.11            62J.52, subdivisions 1, 2, and 5; 62J.60, subdivision 
  1.12            1; 62J.75; 62Q.56; and 62Q.58; Minnesota Statutes 1999 
  1.13            Supplement, sections 45.027, subdivision 6; and 
  1.14            62M.02, subdivision 21; proposing coding for new law 
  1.15            in Minnesota Statutes, chapters 62D; 62J; and 62Q, 
  1.16            repealing Minnesota Statutes 1998, sections 16B.93; 
  1.17            16B.94; 16B.95; 16B.96; 62D.08, subdivision 5; 62D.08, 
  1.18            subdivision 5; and 62Q.07. 
  1.19  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.20     Section 1.  Minnesota Statutes 1999 Supplement, section 
  1.21  45.027, subdivision 6, is amended to read: 
  1.22     Subd. 6.  [VIOLATIONS AND PENALTIES.] The commissioner may 
  1.23  impose a civil penalty not to exceed $10,000 per violation upon 
  1.24  a person who violates any law, rule, or order related to the 
  1.25  duties and responsibilities entrusted to the commissioner unless 
  1.26  a different penalty is specified.  If a civil penalty is imposed 
  1.27  on a health carrier as defined in section 62A.011, the 
  1.28  commissioner must divide 50 percent of the amount among any 
  1.29  policy holder or certificate holder affected by the violation, 
  1.30  unless the commissioner certifies in writing that the division 
  1.31  and distribution to enrollees would be too administratively 
  1.32  complex or that the number of enrollees affected by the penalty 
  2.1   would result in a distribution of less than $50 per enrollee.  
  2.2      Sec. 2.  [62D.021] [ACCREDITATION.] 
  2.3      The commissioner shall accept the results of private 
  2.4   accreditation organizations, professional review organizations, 
  2.5   and other governmental agencies based upon a determination that 
  2.6   the other organization's standards and procedures are no less 
  2.7   stringent than state law.  Documentation of audit procedures and 
  2.8   work papers of these audit organizations must be available to 
  2.9   the commissioner.  The commissioner may use those results in 
  2.10  exercise of regulatory authority.  The commissioner may initiate 
  2.11  and conduct any investigation deemed necessary if there is 
  2.12  suspected violation of law. 
  2.13     Sec. 3.  Minnesota Statutes 1998, section 62D.08, is 
  2.14  amended by adding a subdivision to read: 
  2.15     Subd. 5a.  Every health maintenance organization shall 
  2.16  inform the commissioner of any termination of a provider 
  2.17  contract within ten days after the date that the health 
  2.18  maintenance organization sends out or receives the notice of 
  2.19  cancellation, discontinuance, or termination. 
  2.20     Sec. 4.  Minnesota Statutes 1998, section 62D.17, 
  2.21  subdivision 1, is amended to read: 
  2.22     Subdivision 1.  The commissioner of health may, for any 
  2.23  violation of statute or rule applicable to a health maintenance 
  2.24  organization, or in lieu of suspension or revocation of a 
  2.25  certificate of authority under section 62D.15, levy an 
  2.26  administrative penalty in an amount up to $25,000 for each 
  2.27  violation.  In the case of contracts or agreements made pursuant 
  2.28  to section 62D.05, subdivisions 2 to 4, each contract or 
  2.29  agreement entered into or implemented in a manner which violates 
  2.30  sections 62D.01 to 62D.30 shall be considered a separate 
  2.31  violation.  In determining the level of an administrative 
  2.32  penalty, the commissioner shall consider the following factors: 
  2.33     (1) the number of enrollees affected by the violation; 
  2.34     (2) the effect of the violation on enrollees' health and 
  2.35  access to health services; 
  2.36     (3) if only one enrollee is affected, the effect of the 
  3.1   violation on that enrollee's health; 
  3.2      (4) whether the violation is an isolated incident or part 
  3.3   of a pattern of violations; and 
  3.4      (5) the economic benefits derived by the health maintenance 
  3.5   organization or a participating provider by virtue of the 
  3.6   violation. 
  3.7      Reasonable notice in writing to the health maintenance 
  3.8   organization shall be given of the intent to levy the penalty 
  3.9   and the reasons therefor, and the health maintenance 
  3.10  organization may have 15 days within which to file a written 
  3.11  request for an administrative hearing and review of the 
  3.12  commissioner of health's determination.  Such administrative 
  3.13  hearing shall be subject to judicial review pursuant to chapter 
  3.14  14.  If an administrative penalty is levied, the commissioner 
  3.15  must divide 50 percent of the amount among any enrollee affected 
  3.16  by the violation, unless the commissioner certifies in writing 
  3.17  that the division and distribution to enrollees would be too 
  3.18  administratively complex or that the number of enrollees 
  3.19  affected by the penalty would result in a distribution of less 
  3.20  than $50 per enrollee. 
  3.21     Sec. 5.  Minnesota Statutes 1998, section 62E.04, 
  3.22  subdivision 4, is amended to read: 
  3.23     Subd. 4.  [MAJOR MEDICAL COVERAGE.] Each insurer and 
  3.24  fraternal shall affirmatively offer coverage of major medical 
  3.25  expenses to every applicant who applies to the insurer or 
  3.26  fraternal for a new unqualified policy, which has a lifetime 
  3.27  benefit limit of less than $1,000,000, at the time of 
  3.28  application and annually to every holder of such an unqualified 
  3.29  policy of accident and health insurance renewed by the insurer 
  3.30  or fraternal.  The coverage shall provide that when a covered 
  3.31  individual incurs out-of-pocket expenses of $5,000 or more 
  3.32  within a calendar year for services covered in section 62E.06, 
  3.33  subdivision 1, benefits shall be payable, subject to any 
  3.34  copayment authorized by the commissioner, up to a maximum 
  3.35  lifetime limit of $500,000.  The offer of coverage of major 
  3.36  medical expenses may consist of the offer of a rider on an 
  4.1   existing unqualified policy or a new policy which is a qualified 
  4.2   plan. 
  4.3      Sec. 6.  Minnesota Statutes 1998, section 62J.38, is 
  4.4   amended to read: 
  4.5      62J.38 [COST CONTAINMENT DATA FROM GROUP PURCHASERS.] 
  4.6      (a) The commissioner shall require group purchasers to 
  4.7   submit detailed data on total health care spending for each 
  4.8   calendar year.  Group purchasers shall submit data for the 1993 
  4.9   calendar year by April 1, 1994, and each April 1 thereafter 
  4.10  shall submit data for the preceding calendar year. 
  4.11     (b) The commissioner shall require each group purchaser to 
  4.12  submit data on revenue, expenses, and member months, as 
  4.13  applicable.  Revenue data must distinguish between premium 
  4.14  revenue and revenue from other sources and must also include 
  4.15  information on the amount of revenue in reserves and changes in 
  4.16  reserves.  Expenditure data, including raw data from claims, may 
  4.17  must distinguish between expenses incurred for patient care and 
  4.18  administrative costs.  Expenditure data must be provided 
  4.19  separately for the following categories or and for other 
  4.20  categories required by the commissioner:  physician services, 
  4.21  dental services, other professional services, inpatient hospital 
  4.22  services, outpatient hospital services, emergency, pharmacy 
  4.23  services and other nondurable medical goods, mental health, and 
  4.24  chemical dependency services, other expenditures, subscriber 
  4.25  liability, and administrative costs.  Administrative costs shall 
  4.26  include costs for marketing; advertising; overhead; 
  4.27  underwriting; lobbying; claims processing; provider contracting 
  4.28  and credentialing; detection and prevention of payment for 
  4.29  fraudulent or unjustified requests for reimbursement or 
  4.30  services; concurrent or prospective utilization review as 
  4.31  defined in section 62M.02; expenses incurred to acquire a 
  4.32  hospital, clinic, health care facility, or the assets thereof; 
  4.33  capital costs incurred on behalf of a hospital or clinic; lease 
  4.34  payments; or any other expenses incurred to a hospital, clinic, 
  4.35  or other health care provider pursuant to a partnership, joint 
  4.36  venture, integration, or affiliation agreement.  The 
  5.1   commissioner may require each group purchaser to submit any 
  5.2   other data, including data in unaggregated form, for the 
  5.3   purposes of developing spending estimates, setting spending 
  5.4   limits, and monitoring actual spending and costs. 
  5.5      (c) The commissioner may collect information on: 
  5.6      (1) premiums, benefit levels, managed care procedures, and 
  5.7   other features of health plan companies; 
  5.8      (2) prices, provider experience, and other information for 
  5.9   services less commonly covered by insurance or for which 
  5.10  patients commonly face significant out-of-pocket expenses; and 
  5.11     (3) information on health care services not provided 
  5.12  through health plan companies, including information on prices, 
  5.13  costs, expenditures, and utilization. 
  5.14     (d) All group purchasers shall provide the required data 
  5.15  using a uniform format and uniform definitions, as prescribed by 
  5.16  the commissioner. 
  5.17     Sec. 7.  Minnesota Statutes 1998, section 62J.51, is 
  5.18  amended by adding a subdivision to read: 
  5.19     Subd. 19a.  [UNIFORM EXPLANATION OF BENEFITS 
  5.20  DOCUMENT.] "Uniform explanation of benefits document" means the 
  5.21  document associated with and explaining the details of a group 
  5.22  purchaser's claim adjudication for services rendered, which is 
  5.23  sent to a patient. 
  5.24     Sec. 8.  Minnesota Statutes 1998, section 62J.51, is 
  5.25  amended by adding a subdivision to read: 
  5.26     Subd. 19b.  [UNIFORM REMITTANCE ADVICE REPORT.] "Uniform 
  5.27  remittance advice report" means the document associated with and 
  5.28  explaining the details of a group purchaser's claim adjudication 
  5.29  for services rendered, which is sent to a provider. 
  5.30     Sec. 9.  Minnesota Statutes 1998, section 62J.52, 
  5.31  subdivision 1, is amended to read: 
  5.32     Subdivision 1.  [UNIFORM BILLING FORM HCFA 1450.] (a) On 
  5.33  and after January 1, 1996, all institutional inpatient hospital 
  5.34  services, ancillary services, and institutionally owned or 
  5.35  operated outpatient services rendered by providers in Minnesota, 
  5.36  and institutional or noninstitutional home health services that 
  6.1   are not being billed using an equivalent electronic billing 
  6.2   format, must be billed using the uniform billing form HCFA 1450, 
  6.3   except as provided in subdivision 5. 
  6.4      (b) The instructions and definitions for the use of the 
  6.5   uniform billing form HCFA 1450 shall be in accordance with the 
  6.6   uniform billing form manual specified by the commissioner.  In 
  6.7   promulgating these instructions, the commissioner may utilize 
  6.8   the manual developed by the National Uniform Billing Committee, 
  6.9   as adopted and finalized by the Minnesota uniform billing 
  6.10  committee.  
  6.11     (c) Services to be billed using the uniform billing form 
  6.12  HCFA 1450 include:  institutional inpatient hospital services 
  6.13  and distinct units in the hospital such as psychiatric unit 
  6.14  services, physical therapy unit services, swing bed (SNF)  
  6.15  services, inpatient state psychiatric hospital services, 
  6.16  inpatient skilled nursing facility services, home health 
  6.17  services (Medicare part A), and hospice services; ancillary 
  6.18  services, where benefits are exhausted or patient has no 
  6.19  Medicare part A, from hospitals, state psychiatric hospitals, 
  6.20  skilled nursing facilities, and home health (Medicare part B); 
  6.21  and institutional owned or operated outpatient services such as 
  6.22  waivered services, hospital outpatient services, including 
  6.23  ambulatory surgical center services, hospital referred 
  6.24  laboratory services, hospital-based ambulance services, and 
  6.25  other hospital outpatient services, skilled nursing facilities, 
  6.26  home health, including infusion therapy, freestanding renal 
  6.27  dialysis centers, comprehensive outpatient rehabilitation 
  6.28  facilities (CORF), outpatient rehabilitation facilities (ORF), 
  6.29  rural health clinics, and community mental health centers,; home 
  6.30  health services such as home health intravenous therapy 
  6.31  providers, waivered services, personal care attendants, and 
  6.32  hospice; and any other health care provider certified by the 
  6.33  Medicare program to use this form. 
  6.34     (d) On and after January 1, 1996, a mother and newborn 
  6.35  child must be billed separately, and must not be combined on one 
  6.36  claim form. 
  7.1      Sec. 10.  Minnesota Statutes 1998, section 62J.52, 
  7.2   subdivision 2, is amended to read: 
  7.3      Subd. 2.  [UNIFORM BILLING FORM HCFA 1500.] (a) On and 
  7.4   after January 1, 1996, all noninstitutional health care services 
  7.5   rendered by providers in Minnesota except dental or pharmacy 
  7.6   providers, that are not currently being billed using an 
  7.7   equivalent electronic billing format, must be billed using the 
  7.8   health insurance claim form HCFA 1500, except as provided in 
  7.9   subdivision 5. 
  7.10     (b) The instructions and definitions for the use of the 
  7.11  uniform billing form HCFA 1500 shall be in accordance with the 
  7.12  manual developed by the administrative uniformity committee 
  7.13  entitled standards for the use of the HCFA 1500 form, dated 
  7.14  February 1994, as further defined by the commissioner. 
  7.15     (c) Services to be billed using the uniform billing form 
  7.16  HCFA 1500 include physician services and supplies, durable 
  7.17  medical equipment, noninstitutional ambulance services, 
  7.18  independent ancillary services including occupational therapy, 
  7.19  physical therapy, speech therapy and audiology, podiatry 
  7.20  services, optometry services, mental health licensed 
  7.21  professional services, substance abuse licensed professional 
  7.22  services, nursing practitioner professional services, certified 
  7.23  registered nurse anesthetists, chiropractors, physician 
  7.24  assistants, laboratories, medical suppliers, and other health 
  7.25  care providers such as home health intravenous therapy 
  7.26  providers, personal care attendants, day activity centers, 
  7.27  waivered services, hospice, and other home health services, and 
  7.28  freestanding ambulatory surgical centers. 
  7.29     Sec. 11.  Minnesota Statutes 1998, section 62J.52, 
  7.30  subdivision 5, is amended to read: 
  7.31     Subd. 5.  [STATE AND FEDERAL HEALTH CARE PROGRAMS.] (a) 
  7.32  Skilled nursing facilities and ICF/MR services billed to state 
  7.33  and federal health care programs administered by the department 
  7.34  of human services shall use the form designated by the 
  7.35  department of human services. 
  7.36     (b) On and after July 1, 1996, state and federal health 
  8.1   care programs administered by the department of human services 
  8.2   shall accept the HCFA 1450 for community mental health center 
  8.3   services and shall accept the HCFA 1500 for freestanding 
  8.4   ambulatory surgical center services. 
  8.5      (c) State and federal health care programs administered by 
  8.6   the department of human services shall be authorized to use the 
  8.7   forms designated by the department of human services for 
  8.8   pharmacy services and for child and teen checkup services. 
  8.9      (d) State and federal health care programs administered by 
  8.10  the department of human services shall accept the form 
  8.11  designated by the department of human services, and the HCFA 
  8.12  1500 for supplies, medical supplies, or durable medical 
  8.13  equipment.  Health care providers may choose which form to 
  8.14  submit. 
  8.15     (e) Personal care attendant and waivered services billed on 
  8.16  a fee-for-service basis directly to state and federal health 
  8.17  care programs administered by the department of human services 
  8.18  shall use either the HCFA 1450 or the HCFA 1500 form, as 
  8.19  designated by the department of human services. 
  8.20     Sec. 12.  [62J.581] [STANDARDS FOR MINNESOTA UNIFORM HEALTH 
  8.21  CARE REIMBURSEMENT DOCUMENTS.] 
  8.22     Subdivision 1.  [MINNESOTA UNIFORM REMITTANCE ADVICE 
  8.23  REPORT.] All group purchasers and payers shall provide a uniform 
  8.24  remittance advice report to health care providers when a claim 
  8.25  is adjudicated.  The uniform remittance advice report shall 
  8.26  comply with the standards prescribed in this section. 
  8.27     Subd. 2.  [MINNESOTA UNIFORM EXPLANATION OF BENEFITS 
  8.28  DOCUMENT.] All group purchasers and payers shall provide a 
  8.29  uniform explanation of benefits document to health care patients 
  8.30  when a claim is adjudicated.  The uniform explanation of 
  8.31  benefits document shall comply with the standards prescribed in 
  8.32  this section. 
  8.33     Subd. 3.  [SCOPE.] For purposes of sections 62J.50 to 
  8.34  62J.61, the uniform remittance advice report and the uniform 
  8.35  explanation of benefits document format specified in subdivision 
  8.36  4 shall apply to all health care services delivered by a health 
  9.1   care provider or health care provider organization in Minnesota, 
  9.2   regardless of the location of the payer.  Health care services 
  9.3   not paid on an individual claims basis, such as capitated 
  9.4   payments, are not included in this section.  A health plan 
  9.5   company is excluded from the requirements in subdivisions 1 and 
  9.6   2 if they comply with section 62A.01, subdivisions 2 and 3. 
  9.7      Subd. 4.  [SPECIFICATIONS.] The uniform remittance advice 
  9.8   report and the uniform explanation of benefits document shall be 
  9.9   provided by use of a paper document conforming to the 
  9.10  specifications in this section or by use of the ANSI X12N 835 
  9.11  standard electronic format as established under United States 
  9.12  Code, title 42, sections 1320d to 1320d-8, and as amended from 
  9.13  time to time for the remittance advice.  The commissioner, after 
  9.14  consulting with the administrative uniformity committee, shall 
  9.15  specify the data elements and definitions for the uniform 
  9.16  remittance advice report and the uniform explanation of benefits 
  9.17  document. 
  9.18     Subd. 5.  [EFFECTIVE DATE.] The requirements in 
  9.19  subdivisions 1 and 2 are effective 12 months after the date of 
  9.20  required compliance with the standards for the electronic 
  9.21  remittance advice transaction under United States Code, title 
  9.22  42, sections 1320d to 1320d-8, and as amended from time to 
  9.23  time.  The requirements in subdivisions 1 and 2 apply regardless 
  9.24  of when the health care service was provided to the patient. 
  9.25     Sec. 13.  Minnesota Statutes 1998, section 62J.60, 
  9.26  subdivision 1, is amended to read: 
  9.27     Subdivision 1.  [MINNESOTA HEALTH CARE IDENTIFICATION 
  9.28  CARD.] All individuals with health care coverage shall be issued 
  9.29  health care identification cards by group purchasers as of 
  9.30  January 1, 1998, unless the requirements of section 62A.01, 
  9.31  subdivisions 2 and 3, are met.  The health care identification 
  9.32  cards shall comply with the standards prescribed in this section.
  9.33     Sec. 14.  Minnesota Statutes 1998, section 62J.75, is 
  9.34  amended to read: 
  9.35     62J.75 [CONSUMER ADVISORY BOARD.] 
  9.36     (a) The consumer advisory board consists of 18 members 
 10.1   appointed in accordance with paragraph (b).  All members must be 
 10.2   public, consumer members who: 
 10.3      (1) do not have and never had a material interest in either 
 10.4   the provision of health care services or in an activity directly 
 10.5   related to the provision of health care services, such as health 
 10.6   insurance sales or health plan administration; 
 10.7      (2) are not registered lobbyists; and 
 10.8      (3) are not currently responsible for or directly involved 
 10.9   in the purchasing of health insurance for a business or 
 10.10  organization. 
 10.11     (b) The governor, the speaker of the house of 
 10.12  representatives, and the subcommittee on committees of the 
 10.13  committee on rules and administration of the senate shall each 
 10.14  appoint six members.  Members may be compensated in accordance 
 10.15  with section 15.059, subdivision 3, except that members shall 
 10.16  not receive per diem compensation or reimbursements for child 
 10.17  care expenses. 
 10.18     (c) The board shall advise the commissioners of health and 
 10.19  commerce on the following: 
 10.20     (1) the needs of health care consumers and how to better 
 10.21  serve and educate the consumers on health care concerns and 
 10.22  recommend solutions to identified problems; and 
 10.23     (2) consumer protection issues in the self-insured market, 
 10.24  including, but not limited to, public education needs. 
 10.25     The board also may make recommendations to the legislature 
 10.26  on these issues. 
 10.27     (d) The board and this section expire June 30, 2001 2000. 
 10.28     Sec. 15.  Minnesota Statutes 1999 Supplement, section 
 10.29  62M.02, subdivision 21, is amended to read: 
 10.30     Subd. 21.  [UTILIZATION REVIEW ORGANIZATION.] "Utilization 
 10.31  review organization" means an entity including but not limited 
 10.32  to an insurance company licensed under chapter 60A to offer, 
 10.33  sell, or issue a policy of accident and sickness insurance as 
 10.34  defined in section 62A.01; a health service plan licensed under 
 10.35  chapter 62C; a health maintenance organization licensed under 
 10.36  chapter 62D; a community integrated service network licensed 
 11.1   under chapter 62N; an accountable provider network operating 
 11.2   under chapter 62T; a fraternal benefit society operating under 
 11.3   chapter 64B; a joint self-insurance employee health plan 
 11.4   operating under chapter 62H; a multiple employer welfare 
 11.5   arrangement, as defined in section 3 of the Employee Retirement 
 11.6   Income Security Act of 1974 (ERISA), United States Code, title 
 11.7   29, section 1103, as amended; a third party administrator 
 11.8   licensed under section 60A.23, subdivision 8, which conducts 
 11.9   utilization review and determines certification of an admission, 
 11.10  extension of stay, or other health care services for a Minnesota 
 11.11  resident; or any entity performing utilization review that is 
 11.12  affiliated with, under contract with, or conducting utilization 
 11.13  review on behalf of, a business entity in this 
 11.14  state.  Utilization review organization does not include a 
 11.15  clinic or health care system acting pursuant to a written 
 11.16  delegation agreement with an otherwise regulated utilization 
 11.17  review organization which contracts with the clinic or health 
 11.18  care system.  The regulated utilization review organization is 
 11.19  accountable for the delegated utilization review activities of 
 11.20  the clinic or health care system. 
 11.21     Sec. 16.  Minnesota Statutes 1998, section 62Q.56, is 
 11.22  amended to read: 
 11.23     62Q.56 [CONTINUITY OF CARE.] 
 11.24     Subdivision 1.  [CHANGE IN HEALTH CARE PROVIDER.] (a) If 
 11.25  enrollees are required to access services through selected 
 11.26  primary care providers for coverage, the health plan company 
 11.27  shall prepare a written plan that provides for continuity of 
 11.28  care in the event of contract termination between the health 
 11.29  plan company and any of the contracted primary care providers or 
 11.30  general hospital providers.  The written plan must explain: 
 11.31     (1) how the health plan company will inform affected 
 11.32  enrollees, insureds, or beneficiaries about termination at least 
 11.33  30 days before the termination is effective, if the health plan 
 11.34  company or health care network cooperative has received at least 
 11.35  120 days' prior notice; 
 11.36     (2) how the health plan company will inform the affected 
 12.1   enrollees about what other participating providers are available 
 12.2   to assume care and how it will facilitate an orderly transfer of 
 12.3   its enrollees from the terminating provider to the new provider 
 12.4   to maintain continuity of care; 
 12.5      (3) the procedures by which enrollees will be transferred 
 12.6   to other participating providers, when special medical needs, 
 12.7   special risks, or other special circumstances, such as cultural 
 12.8   or language barriers, require them to have a longer transition 
 12.9   period or be transferred to nonparticipating providers; 
 12.10     (4) who will identify enrollees with special medical needs 
 12.11  or at special risk and what criteria will be used for this 
 12.12  determination; and 
 12.13     (5) how continuity of care will be provided for enrollees 
 12.14  identified as having special needs or at special risk, and 
 12.15  whether the health plan company has assigned this responsibility 
 12.16  to its contracted primary care providers. 
 12.17     (b) If the contract termination was not for 
 12.18  cause, enrollees can request a referral to the terminating 
 12.19  provider for up to 120 days if they have special medical needs 
 12.20  or have other special circumstances, such as cultural or 
 12.21  language barriers. health plans must provide, upon request, a 
 12.22  referral to the terminating provider for the remainder of the 
 12.23  enrollee's life if the enrollee has a terminal condition, and if 
 12.24  the enrollee does not have a terminal condition, for up to 120 
 12.25  days if: 
 12.26     (1) they are engaged in a current episode of treatment for 
 12.27  the following conditions: 
 12.28     (i) an acute condition; 
 12.29     (ii) a life-threatening mental or physical illness; 
 12.30     (iii) pregnancy beyond the first trimester of pregnancy; or 
 12.31     (iv) a disabling or chronic condition that is in an acute 
 12.32  phase; or 
 12.33     (2) the enrollee: 
 12.34     (i) is receiving culturally appropriate services and the 
 12.35  health plan company does not have a provider in its preferred 
 12.36  provider network with special expertise in the delivery of these 
 13.1   culturally appropriate services within the time and distance 
 13.2   requirements of section 62D.124, subdivision 1; or 
 13.3      (ii) does not speak English and the health plan company 
 13.4   does not have a provider in its preferred provider network who 
 13.5   can communicate with the enrollee either directly or through an 
 13.6   interpreter, within the time and distance requirements of 
 13.7   section 62D.124, subdivision 1. 
 13.8   For all requests for referral under clause (1) or (2), the 
 13.9   health plan company must grant the request for referral unless 
 13.10  the enrollee does not meet the criteria provided in the 
 13.11  applicable clause for the request.  If the health plan company 
 13.12  determines that the enrollee does not meet those criteria and 
 13.13  therefore denies the request for a referral, the health plan 
 13.14  company must explain the criteria that it used to determine its 
 13.15  decision on the request for referral.  If a referral is granted, 
 13.16  the health plan company must explain how the continuity of care 
 13.17  will be provided. 
 13.18     The health plan company can may require medical records and 
 13.19  other supporting documentation in support of the requested 
 13.20  referral.  Each request for referral to a terminating provider 
 13.21  shall must be considered by the health plan company on a 
 13.22  case-by-case basis. 
 13.23     (c) If the contract termination was for cause, enrollees 
 13.24  must be notified of the change and transferred to participating 
 13.25  providers in a timely manner so that health care services remain 
 13.26  available and accessible to the affected enrollees.  The health 
 13.27  plan company is not required to refer an enrollee back to the 
 13.28  terminating provider if the termination was for cause. 
 13.29     Subd. 2.  [CHANGE IN HEALTH PLANS.] (a) The health plan 
 13.30  company shall prepare a written plan that provides a process for 
 13.31  coverage determinations for continuity of care for new enrollees 
 13.32  with special needs, special risks, or other special 
 13.33  circumstances, such as cultural or language barriers, who 
 13.34  request continuity of care with their former provider for up to 
 13.35  120 days.  The written plan must explain the criteria that will 
 13.36  be used for determining special needs cases, and how continuity 
 14.1   of care will be provided.  If enrollees are subject to a change 
 14.2   in health plans, the health plan must provide, upon request, a 
 14.3   referral to their current provider for the remainder of the 
 14.4   enrollee's life if the enrollee has a terminal condition, and if 
 14.5   the enrollee does not have a terminal condition, for up to 120 
 14.6   days if they are engaged in a current episode of treatment for 
 14.7   the following conditions: 
 14.8      (1) an acute condition; 
 14.9      (2) a life-threatening mental or physical illness; 
 14.10     (3) pregnancy beyond the first trimester of pregnancy; or 
 14.11     (4) a disabling or chronic condition that is in an acute 
 14.12  phase.  
 14.13     For all requests for referral under this paragraph, the 
 14.14  health plan company must grant the request for referral unless 
 14.15  the enrollee does not meet the criteria provided in this 
 14.16  paragraph. 
 14.17     (b) The health plan company shall prepare a written plan 
 14.18  that provides a process for coverage determinations regarding 
 14.19  continuity of care of up to 120 days for new enrollees with 
 14.20  cultural or language barriers, who request continuity of care 
 14.21  with their former provider.  The written plan must explain the 
 14.22  criteria that will be used to determine whether a need for 
 14.23  continuity of care exists and how it will be provided.  The 
 14.24  written plan must apply to an enrollee if the enrollee: 
 14.25     (1) is receiving culturally appropriate services and the 
 14.26  health plan company does not have a provider in its preferred 
 14.27  provider network with special expertise in the delivery of these 
 14.28  culturally appropriate services within the time and distance 
 14.29  requirements of section 62D.124, subdivision 1; or 
 14.30     (2) does not speak English and the health plan company does 
 14.31  not have a provider or interpreter in its preferred provider 
 14.32  network who can communicate with the enrollee either directly or 
 14.33  through an interpreter, within the time and distance 
 14.34  requirements of section 62D.124, subdivision 1. 
 14.35     (c) This paragraph applies to requests under paragraph (a) 
 14.36  or (b).  The health plan company may require medical records and 
 15.1   other supporting documentation to be submitted with the request 
 15.2   for referral.  Each request for referral to a current provider 
 15.3   shall be considered by the health plan company on a case-by-case 
 15.4   basis.  The health plan company must explain the criteria it 
 15.5   used to make its decision on the request for referral.  If a 
 15.6   referral is granted, the health plan company must explain how 
 15.7   continuity of care will be provided.  
 15.8      (b) (d) This subdivision applies only to group coverage and 
 15.9   continuation and conversion coverage, and applies only to 
 15.10  changes in health plans made by the employer. 
 15.11     Subd. 2a.  [LIMITATIONS.] (a) Subdivisions 1 and 2 apply 
 15.12  only if the enrollee's health care provider agrees to: 
 15.13     (1) accept as payment in full the health plan company's 
 15.14  reimbursement rate for in-network providers for the same or 
 15.15  similar service or, at the discretion of the health plan 
 15.16  company, accept as payment in full the reimbursement rate 
 15.17  specified in a fee schedule established by the health plan 
 15.18  company; 
 15.19     (2) adhere to the health plan company's preauthorization 
 15.20  requirements; and 
 15.21     (3) provide the health plan company with all necessary 
 15.22  medical information related to the care provided to the enrollee.
 15.23     (b) Nothing in this section requires a health plan company 
 15.24  to provide coverage for a health care service or treatment that 
 15.25  is not covered under the enrollee's health plan.  
 15.26     Subd. 3.  [DISCLOSURES DISCLOSURE.] The written plans 
 15.27  required under this section must be made available upon request 
 15.28  to enrollees or prospective enrollees.  Information regarding an 
 15.29  enrollee's rights under this section must be included in member 
 15.30  contracts or certificates of coverage and must be provided by a 
 15.31  health plan company upon request of an enrollee or prospective 
 15.32  enrollee.  
 15.33     Sec. 17.  Minnesota Statutes 1998, section 62Q.58, is 
 15.34  amended to read: 
 15.35     62Q.58 [ACCESS TO SPECIALTY CARE.] 
 15.36     Subdivision 1.  [STANDING REFERRAL.] A health plan company 
 16.1   shall establish a procedure by which an enrollee may apply 
 16.2   for and, if appropriate, receive a standing referral to a health 
 16.3   care provider who is a specialist if a referral to a specialist 
 16.4   is required for coverage.  This procedure for a standing 
 16.5   referral must specify the necessary criteria and conditions, 
 16.6   which must be met in order for an enrollee to obtain a standing 
 16.7   referral managed care review and approval an enrollee must 
 16.8   obtain before such a standing referral is permitted. 
 16.9      Subd. 1a.  [MANDATORY STANDING REFERRAL.] An enrollee who 
 16.10  requests a standing referral to a specialist qualified to treat 
 16.11  the specific condition described in clauses (1) to (3) must be 
 16.12  given a standing referral to such a specialist if benefits for 
 16.13  such treatment are provided under the health plan and the 
 16.14  enrollee meets any of the following conditions:  
 16.15     (1) a chronic health condition that is in an acute phase; 
 16.16     (2) a life-threatening mental or physical illness; 
 16.17     (3) pregnancy beyond the first trimester of pregnancy; 
 16.18     (4) a degenerative disease or disability; or 
 16.19     (5) other condition or disease of sufficient seriousness 
 16.20  and complexity to require treatment by a specialist. 
 16.21     Subd. 2.  [COORDINATION OF SERVICES.] A primary care 
 16.22  provider or primary care group shall remain responsible for 
 16.23  coordinating the care of an enrollee who has received a standing 
 16.24  referral to a specialist.  The specialist shall not make any 
 16.25  secondary referrals related to primary care services without 
 16.26  prior approval by the primary care provider or primary care 
 16.27  group.  However, An enrollee with a standing referral to a 
 16.28  specialist may request primary care services from that 
 16.29  specialist that the specialist manage all medical care 
 16.30  appropriate to the enrollee for the condition, or related 
 16.31  condition, for which the enrollee was referred.  The specialist, 
 16.32  in agreement with the enrollee and primary care provider or 
 16.33  primary care group, may elect to provide primary care services 
 16.34  to that the enrollee, authorize tests and services, and make 
 16.35  secondary referrals according to procedures established by the 
 16.36  health plan company.  
 17.1      Subd. 3.  [DISCLOSURE.] Information regarding referral 
 17.2   procedures must be included in member contracts or certificates 
 17.3   of coverage and must be provided to an enrollee or prospective 
 17.4   enrollee by a health plan company upon request. 
 17.5      Sec. 18.  [62Q.75] [MEDICAL CLINICAL TRIALS.] 
 17.6      Subdivision 1.  [DEFINITIONS.] For purposes of this 
 17.7   section, "patient cost" means the cost of a medically necessary 
 17.8   health care service covered and provided by the health plan that 
 17.9   would normally be provided to or be available to the patient, 
 17.10  whether or not the patient participated in a clinical trial. 
 17.11  Patient cost does not include: 
 17.12     (1) the cost of an investigational drug or device; 
 17.13     (2) the cost of a nonhealth care service that an enrollee 
 17.14  may be required to receive as a result of treatment being 
 17.15  provided for the purposes of a clinical trial; 
 17.16     (3) costs associated with managing the research associated 
 17.17  with a clinical trial; or 
 17.18     (4) costs that would not be covered under the enrollee's 
 17.19  health plan. 
 17.20     Subd. 2.  [COVERAGE REQUIRED.] A health plan company shall 
 17.21  provide coverage for patient costs incurred by an enrollee in a 
 17.22  clinical trial for the treatment of a life-threatening condition 
 17.23  or prevention, early detection, and treatment of cancer if: 
 17.24     (1) the treatment is being provided or the studies are 
 17.25  being conducted in a phase III or phase IV clinical trial for 
 17.26  cancer, or the treatment is being provided in a phase III or 
 17.27  phase IV clinical trial for any other life-threatening 
 17.28  condition; 
 17.29     (2) the treatment is being provided in a clinical trial 
 17.30  approved by: 
 17.31     (i) the National Institute of Health; 
 17.32     (ii) a cooperative group or center of the National 
 17.33  Institute of Health; 
 17.34     (iii) the federal Food and Drug Administration in the form 
 17.35  of an investigational new drug application; 
 17.36     (iv) the federal Department of Veterans Affairs; 
 18.1      (v) the federal Department of Defense; or 
 18.2      (vi) a qualified research entity that meets the criteria 
 18.3   for the center of the National Institute of Health support grant 
 18.4   eligibility. 
 18.5      (3) the proposed treatment has been reviewed and approved 
 18.6   by a qualified institutional review board; and 
 18.7      (4) the facility and personnel providing the treatment are 
 18.8   providing treatment within their scope of practice, experience, 
 18.9   and training. 
 18.10     Subd. 3.  [PARTICIPATING PROVIDERS; COST SHARING.] A health 
 18.11  plan company may require that a qualified individual participate 
 18.12  in the trial through a participating provider if the provider 
 18.13  will accept the individual as a participant.  A health plan 
 18.14  company may apply cost-sharing requirements and other 
 18.15  limitations comparable to those applied to coverage for other 
 18.16  health services under the plan. 
 18.17     Sec. 19.  [QUALITY OF PATIENT CARE.] 
 18.18     The commissioner of health shall evaluate the feasibility 
 18.19  of collecting data on the quality of patient care provided in 
 18.20  hospitals, outpatient surgical centers, and other health care 
 18.21  facilities.  In this evaluation, the commissioner shall examine 
 18.22  the appropriate roles of the public and private sectors and the 
 18.23  need for risk adjusting data.  The evaluation must consider 
 18.24  mechanisms to identify the quality of nursing care provided to 
 18.25  consumers by examining variables such as skin breakdown and 
 18.26  patient injuries.  Any plan developed to collect data must also 
 18.27  address issues related to the release of this data in a useful 
 18.28  form to the public. 
 18.29     Sec. 20.  [REPEALER.] 
 18.30     Minnesota Statutes 1998, sections 16B.93; 16B.94; 16B.95; 
 18.31  16B.96; 62D.08, subdivision 5; and 62Q.07, are repealed. 
 18.32     Sec. 21.  [EFFECTIVE DATE.] 
 18.33     Sections 1, 4, 6, and 16 to 19 are effective for all new 
 18.34  policies, contracts, or health benefit plans issued or renewed 
 18.35  on or after January 1, 2001.