1.1                          A bill for an act 
  1.2             relating to insurance; regulating action plans of 
  1.3             certain health plan companies; requiring an 
  1.4             affirmative provider consent to participate in a 
  1.5             network under a category of coverage; requiring 
  1.6             disclosure of changes in a provider's contract; 
  1.7             amending Minnesota Statutes 2000, sections 62Q.07; 
  1.8             62Q.74, subdivisions 2, 3, and 4; proposing coding for 
  1.9             new law in Minnesota Statutes, chapter 62Q.  
  1.10  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.11     Section 1.  Minnesota Statutes 2000, section 62Q.07, is 
  1.12  amended to read: 
  1.13     62Q.07 [ACTION PLANS.] 
  1.14     Subdivision 1.  [ACTION PLANS REQUIRED.] (a) To increase 
  1.15  public awareness and accountability of health plan companies, 
  1.16  all health plan companies that issue or renew a health plan, as 
  1.17  defined in section 62Q.01 managed care plan, as defined in 
  1.18  section 62U.01, must annually file with the applicable 
  1.19  commissioner an action plan that satisfies the requirements of 
  1.20  this section beginning July 1, 1994, as a condition of doing 
  1.21  business in Minnesota.  For purposes of this subdivision, 
  1.22  "health plan" includes the coverages described in section 
  1.23  62A.011, subdivision 3, clause (10).  Each health plan company 
  1.24  must also file its action plan with the information 
  1.25  clearinghouse.  Action plans are required solely to provide 
  1.26  information to consumers, purchasers, and the larger community 
  1.27  as a first step toward greater accountability of health plan 
  2.1   companies.  The sole function of the commissioner in relation to 
  2.2   the action plans is to ensure that each health plan company 
  2.3   files a complete action plan, that the action plan is truthful 
  2.4   and not misleading, and that the action plan is reviewed by 
  2.5   appropriate community agencies. 
  2.6      (b) If a the commissioner responsible for regulating a 
  2.7   health plan company required to file an action plan under this 
  2.8   section has reason to believe an action plan is false or 
  2.9   misleading, the commissioner may conduct an investigation to 
  2.10  determine whether the action plan is truthful and not 
  2.11  misleading, and may require the health plan company to submit 
  2.12  any information that the commissioner reasonably deems necessary 
  2.13  to complete the investigation.  If the commissioner determines 
  2.14  that an action plan is false or misleading, the commissioner may 
  2.15  require the health plan company to file an amended plan or may 
  2.16  take any action authorized under chapter 72A. 
  2.17     Subd. 2.  [CONTENTS OF ACTION PLANS.] (a) An action plan 
  2.18  must include a detailed description of all of the health plan 
  2.19  company's methods and procedures, standards, qualifications, 
  2.20  criteria, and credentialing requirements for designating the 
  2.21  providers who are eligible to participate in the health plan 
  2.22  company's provider network, including any limitations on the 
  2.23  numbers of providers to be included in the network.  This 
  2.24  description must be updated by the health plan company and filed 
  2.25  with the applicable agency on a quarterly basis.  
  2.26     (b) An action plan must include the number of full-time 
  2.27  equivalent physicians, by specialty, nonphysician providers, and 
  2.28  allied health providers used to provide services.  The action 
  2.29  plan must also describe how the health plan company intends to 
  2.30  encourage the use of nonphysician providers, midlevel 
  2.31  practitioners, and allied health professionals, through at least 
  2.32  consumer education, physician education, and referral and 
  2.33  advisement systems.  The annual action plan must also include 
  2.34  data that is broken down by type of provider, reflecting actual 
  2.35  utilization of midlevel practitioners and allied professionals 
  2.36  by enrollees of the health plan company during the previous 
  3.1   year.  Until July 1, 1995, a health plan company may use 
  3.2   estimates if actual data is not available.  For purposes of this 
  3.3   paragraph, "provider" has the meaning given in section 62J.03, 
  3.4   subdivision 8.  
  3.5      (c) An action plan must include a description of the health 
  3.6   plan company's policy on determining the number and the type of 
  3.7   providers that are necessary to deliver cost-effective health 
  3.8   care to its enrollees.  The action plan must also include the 
  3.9   health plan company's strategy, including provider recruitment 
  3.10  and retention activities, for ensuring that sufficient providers 
  3.11  are available to its enrollees. 
  3.12     (d) An action plan must include a description of actions 
  3.13  taken or planned by the health plan company to ensure that 
  3.14  information from report cards, outcome studies, and complaints 
  3.15  is used internally to improve quality of the services provided 
  3.16  by the health plan company. 
  3.17     (e) An action plan must include a detailed description of 
  3.18  the health plan company's policies and procedures for enrolling 
  3.19  and serving high risk and special needs populations.  This 
  3.20  description must also include the barriers that are present for 
  3.21  the high risk and special needs population and how the health 
  3.22  plan company is addressing these barriers in order to provide 
  3.23  greater access to these populations.  "High risk and special 
  3.24  needs populations" includes, but is not limited to, recipients 
  3.25  of medical assistance, general assistance medical care, and 
  3.26  MinnesotaCare; persons with chronic conditions or disabilities; 
  3.27  individuals within certain racial, cultural, and ethnic 
  3.28  communities; individuals and families with low income; 
  3.29  adolescents; the elderly; individuals with limited or no English 
  3.30  language proficiency; persons with high-cost preexisting 
  3.31  conditions; homeless persons; chemically dependent persons; 
  3.32  persons with serious and persistent mental illness; children 
  3.33  with severe emotional disturbance; and persons who are at high 
  3.34  risk of requiring treatment.  For purposes of this paragraph, 
  3.35  "provider" has the meaning given in section 62J.03, subdivision 
  3.36  8. 
  4.1      (f) An action plan must include a general description of 
  4.2   any action the health plan company has taken and those it 
  4.3   intends to take to offer health coverage options to rural 
  4.4   communities and other communities not currently served by the 
  4.5   health plan company. 
  4.6      (g) A health plan company other than a large managed care 
  4.7   plan company may satisfy any of the requirements of the action 
  4.8   plan in paragraphs (a) to (f) by stating that it has no 
  4.9   policies, procedures, practices, or requirements, either written 
  4.10  or unwritten, or formal or informal, and has undertaken no 
  4.11  activities or plans on the issues required to be addressed in 
  4.12  the action plan, provided that the statement is truthful and not 
  4.13  misleading.  For purposes of this paragraph, "large managed care 
  4.14  plan company" means a health maintenance organization or other 
  4.15  health plan company that employs or contracts with health care 
  4.16  providers, that has more than 50,000 enrollees in this state.  
  4.17  If a health plan company employs or contracts with providers for 
  4.18  some of its health plans and does not do so for other health 
  4.19  plans that it offers, the health plan company is a large managed 
  4.20  care plan company if it has more than 50,000 enrollees in this 
  4.21  state in health plans for which it does employ or contract with 
  4.22  providers. 
  4.23     Sec. 2.  Minnesota Statutes 2000, section 62Q.74, 
  4.24  subdivision 2, is amended to read: 
  4.25     Subd. 2.  [PROVIDER CONSENT REQUIRED.] (a) No network 
  4.26  organization shall require a health care provider to participate 
  4.27  in a network under a category of coverage that differs from the 
  4.28  category or categories of coverage to which the existing 
  4.29  contract between the network organization and the provider 
  4.30  applies, without the affirmative consent of the provider 
  4.31  obtained under subdivision 3.  
  4.32     (b) This section does not apply to situations in which the 
  4.33  network organization wishes the provider to participate in a new 
  4.34  or different plan or other arrangement within a category of 
  4.35  coverage that is already provided for in an existing contract 
  4.36  between the network organization and the provider. 
  5.1      (c) Compliance with this section may not be waived in a 
  5.2   contract or otherwise. 
  5.3      Sec. 3.  Minnesota Statutes 2000, section 62Q.74, 
  5.4   subdivision 3, is amended to read: 
  5.5      Subd. 3.  [CONSENT PROCEDURE.] (a) The network 
  5.6   organization, if it wishes to apply an existing contract with a 
  5.7   provider to a different category of coverage, shall first notify 
  5.8   the provider in writing.  The written notice must include at 
  5.9   least the following: 
  5.10     (1) the network organization's name, address, and telephone 
  5.11  number, and the name of the specific network, if it differs from 
  5.12  that of the network organization; 
  5.13     (2) a description of the proposed new category of coverage; 
  5.14     (3) the names of all payers expected by the network 
  5.15  organization to use the network for the new category of 
  5.16  coverage; 
  5.17     (4) the approximate number of current enrollees of the 
  5.18  network organization in that category of coverage within the 
  5.19  provider's geographical area; 
  5.20     (5) a disclosure of all contract terms of the proposed new 
  5.21  category of coverage, including the discount or reduced fees, 
  5.22  care guidelines, utilization review criteria, prior 
  5.23  authorization process, and dispute resolution process; 
  5.24     (6) a form for the provider's convenience in accepting or 
  5.25  declining participation in the proposed new category of 
  5.26  coverage, provided that the provider need not use that form in 
  5.27  responding; and 
  5.28     (7) a statement informing the provider of the provisions of 
  5.29  paragraph (b). 
  5.30     (b) If the provider does not decline participation within 
  5.31  30 days after the postmark date of the notice, the provider is 
  5.32  deemed to have accepted the proposed new category of 
  5.33  coverage Unless the provider has affirmatively agreed to 
  5.34  participate within 60 days after the postmark date of the 
  5.35  notice, the provider is deemed to have not accepted the proposed 
  5.36  new category of coverage. 
  6.1      Sec. 4.  Minnesota Statutes 2000, section 62Q.74, 
  6.2   subdivision 4, is amended to read: 
  6.3      Subd. 4.  [CONTRACT TERMINATION RESTRICTED.] (a) A network 
  6.4   organization must not terminate an existing contract with a 
  6.5   provider, or fail to honor the contract in good faith, based 
  6.6   solely on the provider's decision not to accept a proposed new 
  6.7   category of coverage.  The most recent agreed-upon contractual 
  6.8   obligations remain in force until the existing contract's 
  6.9   renewal or termination date. 
  6.10     (b) If a provider declines to participate in a category of 
  6.11  coverage, the network organization must permit the provider the 
  6.12  opportunity to participate in that category of coverage when the 
  6.13  organization determines a demographic or geographic need. 
  6.14     Sec. 5.  [62Q.745] [PROVIDER CONTRACT AMENDMENT 
  6.15  DISCLOSURE.] 
  6.16     (a) Any amendment or change in the terms of an existing 
  6.17  contract between a network organization and a health care 
  6.18  provider must be disclosed to the provider. 
  6.19     (b) Any amendment or change in the contract that alters the 
  6.20  financial reimbursement or performance requirements must be 
  6.21  disclosed to the provider before the amendment or change is 
  6.22  deemed to be in effect. 
  6.23     (c) For purposes of this section, "network organization" 
  6.24  and "health care provider" or "provider" have the meanings given 
  6.25  in section 62Q.74. 
  6.26     Sec. 6.  [62Q.746] [ACCESS TO CERTAIN INFORMATION REGARDING 
  6.27  PROVIDERS.] 
  6.28     Upon request of the commissioner, a health plan company 
  6.29  licensed under chapters 62C and 62D, must provide the following 
  6.30  information: 
  6.31     (1) a detailed description of the health plan company's 
  6.32  methods and procedures, standards, qualifications, criteria, and 
  6.33  credentialing requirements for designating the providers who are 
  6.34  eligible to participate in the health plan company's provider 
  6.35  network, including any limitations on the numbers of providers 
  6.36  to be included in the network; 
  7.1      (2) the number of full-time equivalent physicians, by 
  7.2   specialty, nonphysician providers, and allied health providers 
  7.3   used to provide services; and 
  7.4      (3) summary data that is broken down by type of provider, 
  7.5   reflecting actual utilization of network and non-network 
  7.6   practitioners and allied professionals by enrollees of the 
  7.7   health plan company.