HF 779

2nd Unofficial Engrossment - 88th Legislature (2013 - 2014)

Posted on 05/16/2013 11:11 a.m.

1.1A bill for an act 1.2relating to health plan regulation; regulating policy and contract coverages; 1.3conforming state law to federal requirements; establishing health plan market 1.4rules; modifying the designation of essential community providers;amending 1.5Minnesota Statutes 2012, sections 43A.23, subdivision 1; 43A.317, subdivision 1.66; 60A.08, subdivision 15; 62A.011, subdivision 3, by adding subdivisions; 1.762A.02, by adding a subdivision; 62A.03, subdivision 1; 62A.04, subdivision 1.82; 62A.047; 62A.049; 62A.136; 62A.149, subdivision 1; 62A.17, subdivisions 1.92, 6; 62A.21, subdivision 2b; 62A.28, subdivision 2; 62A.302; 62A.615; 1.1062A.65, subdivisions 3, 5, 6, 7, by adding subdivisions; 62C.14, subdivision 5; 1.1162C.142, subdivision 2; 62D.07, subdivision 3; 62D.095; 62D.124, subdivision 1.124; 62D.181, subdivision 7; 62E.02, by adding a subdivision; 62E.04, subdivision 1.134, by adding a subdivision; 62E.06, subdivision 1; 62E.09; 62E.10, subdivision 1.147; 62H.04; 62L.02, subdivisions 11, 14a, 26, by adding a subdivision; 62L.03, 1.15subdivisions 1, 3, 4, 6; 62L.045, subdivisions 2, 4; 62L.05, subdivision 10; 1.1662L.06; 62L.08; 62L.12, subdivision 2; 62M.05, subdivision 3a; 62M.06, 1.17subdivision 1; 62Q.01, by adding subdivisions; 62Q.021; 62Q.17, subdivision 1.186; 62Q.18, by adding a subdivision; 62Q.23; 62Q.43, subdivision 2; 62Q.47; 1.1962Q.52; 62Q.55; 62Q.68, subdivision 1; 62Q.69, subdivision 3; 62Q.70, 1.20subdivisions 1, 2; 62Q.71; 62Q.73; 62Q.75, subdivision 1; 62Q.80, subdivision 1.212; 72A.20, subdivision 35; 145.414; 471.61, subdivision 1a; proposing coding 1.22for new law in Minnesota Statutes, chapters 62A; 62Q; proposing coding for new 1.23law as Minnesota Statutes, chapter 62K; repealing Minnesota Statutes 2012, 1.24sections 62A.615; 62A.65, subdivision 6; 62E.02, subdivision 7; 62E.16; 62E.20; 1.2562L.02, subdivisions 4, 18, 19, 23, 24; 62L.05, subdivisions 1, 2, 3, 4, 4a, 5, 6, 7, 1.2611, 12, 13; 62L.081; 62L.10, subdivision 5; 62Q.37, subdivision 5. 1.27BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 1.28ARTICLE 1 1.29CONFORMING STATE LAW TO AFFORDABLE CARE ACT 1.30    Section 1. Minnesota Statutes 2012, section 43A.23, subdivision 1, is amended to read: 1.31    Subdivision 1. General. (a) The commissioner is authorized to request proposals 1.32or to negotiate and to enter into contracts with parties which in the judgment of the 2.1commissioner are best qualified to provide service to the benefit plans. Contracts entered 2.2into are not subject to the requirements of sections 16C.16 to 16C.19. The commissioner 2.3may negotiate premium rates and coverage. The commissioner shall consider the cost of 2.4the plans, conversion options relating to the contracts, service capabilities, character, 2.5financial position, and reputation of the carriers, and any other factors which the 2.6commissioner deems appropriate. Each benefit contract must be for a uniform term of at 2.7least one year, but may be made automatically renewable from term to term in the absence 2.8of notice of termination by either party. A carrier licensed under chapter 62A is exempt 2.9from the taxes imposed by chapter 297I on premiums paid to it by the state. 2.10    (b) All self-insured hospital and medical service products must comply with coverage 2.11mandates, data reporting, and consumer protection requirements applicable to the licensed 2.12carrier administering the product, had the product been insured, including chapters 62J, 2.1362M, and 62Q. Any self-insured products that limit coverage to a network of providers 2.14or provide different levels of coverage between network and nonnetwork providers shall 2.15comply with section 62D.123 and geographic access standards for health maintenance 2.16organizations adopted by the commissioner of health in rule under chapter 62D. 2.17    (c) Notwithstanding paragraph (b), a self-insured hospital and medical product 2.18offered under sections 43A.22 to 43A.30 is not required to extend dependent coverage 2.19to an eligible employee's unmarried child under the age of 25 to the full extent required 2.20under chapters 62A and 62L. Dependent new text begin child new text end coverage must, at a minimum, extend to an 2.21eligible employee's unmarried new text begin dependent new text end child who is under the age of 19 or an unmarried 2.22child under the age of 25 who is a full-time student. A person who is at least 19 years of 2.23age but who is under the age of 25 and who is not a full-time student must be permitted 2.24to be enrolled as a dependent of an eligible employee until age 25 if the person: new text begin to the new text end 2.25 new text begin limiting age as defined in section 62Q.01, subdivision 9, disabled children to the extent new text end 2.26 new text begin required in sections 62A.14 and 62A.141, and dependent grandchildren to the extent new text end 2.27 new text begin required in sections 62A.042 and 62A.302. new text end 2.28(1) was a full-time student immediately prior to being ordered into active military 2.29service, as defined in section 190.05, subdivision 5b or 5c; 2.30(2) has been separated or discharged from active military service; and 2.31(3) would be eligible to enroll as a dependent of an eligible employee, except that 2.32the person is not a full-time student. 2.33The definition of "full-time student" for purposes of this paragraph includes any student 2.34who by reason of illness, injury, or physical or mental disability as documented by 2.35a physician is unable to carry what the educational institution considers a full-time 2.36course load so long as the student's course load is at least 60 percent of what otherwise 3.1is considered by the institution to be a full-time course load. Any notice regarding 3.2termination of coverage due to attainment of the limiting age must include information 3.3about this definition of "full-time student." 3.4    (d) Beginning January 1, 2010, the health insurance benefit plans offered in the 3.5commissioner's plan under section 43A.18, subdivision 2, and the managerial plan under 3.6section 43A.18, subdivision 3, must include an option for a health plan that is compatible 3.7with the definition of a high-deductible health plan in section 223 of the United States 3.8Internal Revenue Code. 3.9 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 3.10    Sec. 2. Minnesota Statutes 2012, section 43A.317, subdivision 6, is amended to read: 3.11    Subd. 6. Individual eligibility. (a) Procedures. The commissioner shall establish 3.12procedures for eligible employees and other eligible individuals to apply for coverage 3.13through the program. 3.14(b) Employees. An employer shall determine when it applies to the program the 3.15criteria its employees must meet to be eligible for coverage under its plan. An employer 3.16may subsequently change the criteria annually or at other times with approval of the 3.17commissioner. The criteria must provide that new employees become eligible for coverage 3.18after a probationary period of at least 30 days, but no more than 90 days. 3.19(c) Other individuals. An employer may elect to cover under its plan: 3.20(1) the spouse, dependent children new text begin to the limiting age as defined in section 62Q.01, new text end 3.21 new text begin subdivision 9, disabled children to the extent required in sections 62A.14 and 62A.141 new text end , 3.22and dependent grandchildren of a covered employee new text begin to the extent required in sections new text end 3.23 new text begin 62A.042 and 62A.302 new text end ; 3.24(2) a retiree who is eligible to receive a pension or annuity from the employer and a 3.25covered retiree's spouse, dependent children new text begin to the limiting age as defined in section new text end 3.26 new text begin 62Q.01, subdivision 9, disabled children to the extent required in sections 62A.14 and new text end 3.27 new text begin 62A.141 new text end , and dependent grandchildren new text begin to the extent required in sections 62A.042 and new text end 3.28 new text begin 62A.302 new text end ; 3.29(3) the surviving spouse, dependent children new text begin to the limiting age as defined in section new text end 3.30 new text begin 62Q.01, subdivision 9, disabled children new text end , and dependent grandchildren of a deceased 3.31employee or retiree, if the spouse, children, or grandchildren were covered at the time of 3.32the death; 3.33(4) a covered employee who becomes disabled, as provided in sections 62A.147 3.34and 62A.148; or 4.1(5) any other categories of individuals for whom group coverage is required by 4.2state or federal law. 4.3An employer shall determine when it applies to the program the criteria individuals 4.4in these categories must meet to be eligible for coverage. An employer may subsequently 4.5change the criteria annually, or at other times with approval of the commissioner. The 4.6criteria for dependent children new text begin to the limiting age as defined in section 62Q.01, subdivision new text end 4.7 new text begin 9, disabled children, new text end and dependent grandchildren may be no more inclusive than the 4.8criteria under section 43A.18, subdivision 2. This paragraph shall not be interpreted 4.9as relieving the program from compliance with any federal and state continuation of 4.10coverage requirements. 4.11(d) Waiver and late entrance. An eligible individual may waive coverage at the 4.12time the employer joins the program or when coverage first becomes available. The 4.13commissioner may establish a preexisting condition exclusion of not more than 18 months 4.14for late entrants as defined in section 62L.02, subdivision 19. 4.15(e) Continuation coverage. The program shall provide all continuation coverage 4.16required by state and federal law. 4.17 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 4.18    Sec. 3. Minnesota Statutes 2012, section 60A.08, subdivision 15, is amended to read: 4.19    Subd. 15. Classification of insurance filings data. (a) All forms, rates, and related 4.20information filed with the commissioner under section 61A.02 shall be nonpublic data 4.21until the filing becomes effective. 4.22    (b) All forms, rates, and related information filed with the commissioner under 4.23section 62A.02 shall be nonpublic data until the filing becomes effective. 4.24    (c) All forms, rates, and related information filed with the commissioner under 4.25section 62C.14, subdivision 10, shall be nonpublic data until the filing becomes effective. 4.26    (d) All forms, rates, and related information filed with the commissioner under 4.27section 70A.06 shall be nonpublic data until the filing becomes effective. 4.28    (e) All forms, rates, and related information filed with the commissioner under 4.29section 79.56 shall be nonpublic data until the filing becomes effective. 4.30 new text begin (f) Notwithstanding paragraphs (b) and (c), for all rate increases subject to review new text end 4.31 new text begin under section 2794 of the Public Health Services Act and any amendments to, or new text end 4.32 new text begin regulations, or guidance issued under the act that are filed with the commissioner on or new text end 4.33 new text begin after September 1, 2011, the commissioner: new text end 4.34 new text begin (1) may acknowledge receipt of the information; new text end 4.35 new text begin (2) may acknowledge that the corresponding rate filing is pending review; new text end 5.1 new text begin (3) must provide public access from the Department of Commerce's Web site to parts new text end 5.2 new text begin I and II of the Preliminary Justifications of the rate increases subject to review; and new text end 5.3 new text begin (4) must provide notice to the public on the Department of Commerce's Web site of the new text end 5.4 new text begin review of the proposed rate, which must include a statement that the public has 30 calendar new text end 5.5 new text begin days to submit written comments to the commissioner on the rate filing subject to review. new text end 5.6 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 5.7    Sec. 4. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision 5.8to read: 5.9     new text begin Subd. 1a. new text end new text begin Affordable Care Act. new text end new text begin "Affordable Care Act" means the federal Patient new text end 5.10 new text begin Protection and Affordable Care Act, Public Law 111-148, as amended, including the new text end 5.11 new text begin federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and new text end 5.12 new text begin any amendments to, and any federal guidance or regulations issued under, these acts. new text end 5.13 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 5.14    Sec. 5. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision 5.15to read: 5.16     new text begin Subd. 1b. new text end new text begin Grandfathered plan. new text end new text begin "Grandfathered plan" means a health plan in which new text end 5.17 new text begin an individual was enrolled on March 23, 2010, for as long as it maintains that status in new text end 5.18 new text begin accordance with the Affordable Care Act. Unless otherwise specified, grandfathered plans new text end 5.19 new text begin include both individual and group health plans. new text end 5.20 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 5.21    Sec. 6. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision 5.22to read: 5.23     new text begin Subd. 1c. new text end new text begin Group health plan. new text end new text begin "Group health plan" means a policy or certificate new text end 5.24 new text begin issued to an employer or an employee organization that is both: new text end 5.25 new text begin (1) a health plan as defined in subdivision 3; and new text end 5.26 new text begin (2) an employee welfare benefit plan as defined in the Employee Retirement Income new text end 5.27 new text begin Security Act of 1974, United States Code, title 29, section 1002, if the plan provides new text end 5.28 new text begin payment for medical care to employees, including both current and former employees, or new text end 5.29 new text begin their dependents, directly or through insurance, reimbursement, or otherwise, including new text end 5.30 new text begin employee welfare benefit plans specifically exempt from the provisions of the Employee new text end 5.31 new text begin Retirement Income Security Act of 1974 under United States Code, title 29, section 1003. new text end 6.1 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 6.2    Sec. 7. Minnesota Statutes 2012, section 62A.011, subdivision 3, is amended to read: 6.3    Subd. 3. Health plan. "Health plan" means a policy or certificate of accident and 6.4sickness insurance as defined in section 62A.01 offered by an insurance company licensed 6.5under chapter 60A; a subscriber contract or certificate offered by a nonprofit health 6.6service plan corporation operating under chapter 62C; a health maintenance contract or 6.7certificate offered by a health maintenance organization operating under chapter 62D; a 6.8health benefit certificate offered by a fraternal benefit society operating under chapter 6.964B; or health coverage offered by a joint self-insurance employee health plan operating 6.10under chapter 62H. Health plan means individual and group coverage, unless otherwise 6.11specified. Health plan does not include coverage that is: 6.12(1) limited to disability or income protection coverage; 6.13(2) automobile medical payment coverage; 6.14(3) supplemental new text begin liability insurance, including general liability insurance and new text end 6.15 new text begin automobile liability insurance, or coverage issued as a supplement new text end to liability insurance; 6.16(4) designed solely to provide payments on a per diem, fixed indemnity, or 6.17non-expense-incurred basis new text begin , including coverage only for a specified disease or illness or new text end 6.18 new text begin hospital indemnity or other fixed indemnity insurance, if the benefits are provided under a new text end 6.19 new text begin separate policy, certificate, or contract for insurance; there is no coordination between the new text end 6.20 new text begin provision of benefits and any exclusion of benefits under any group health plan maintained new text end 6.21 new text begin by the same plan sponsor; and the benefits are paid with respect to an event without regard new text end 6.22 new text begin to whether benefits are provided with respect to such an event under any group health new text end 6.23 new text begin plan maintained by the same plan sponsor new text end ; 6.24(5) credit accident and health insurance as defined in section 62B.02; 6.25(6) designed solely to provide hearing, dental, or vision care; 6.26(7) blanket accident and sickness insurance as defined in section 62A.11; 6.27(8) accident-only coverage; 6.28(9) a long-term care policy as defined in section 62A.46 or 62S.01; 6.29(10) issued as a supplement to Medicare, as defined in sections 62A.3099 to 6.3062A.44 , or policies, contracts, or certificates that supplement Medicare issued by health 6.31maintenance organizations or those policies, contracts, or certificates governed by section 6.321833 or 1876 new text begin , section 1851, et seq.; or section 1860D-1, et seq., of title XVIII new text end of the 6.33federal Social Security Act, United States Code, title 42, section 1395, et seq., as amended; 6.34(11) workers' compensation insurance; or 7.1(12) issued solely as a companion to a health maintenance contract as described in 7.2section 62D.12, subdivision 1a, so long as the health maintenance contract meets the 7.3definition of a health plan. new text begin ; new text end 7.4 new text begin (13) coverage for on-site medical clinics; or new text end 7.5 new text begin (14) coverage supplemental to the coverage provided under United States Code, new text end 7.6 new text begin title 10, chapter 55, Civilian Health and Medical Program of the Uniformed Services new text end 7.7 new text begin (CHAMPUS). new text end 7.8 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 7.9    Sec. 8. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision 7.10to read: 7.11     new text begin Subd. 4. new text end new text begin Individual health plan. new text end new text begin "Individual health plan" means a health plan as new text end 7.12 new text begin defined in subdivision 3 that is offered to individuals in the individual market as defined new text end 7.13 new text begin in subdivision 5, but does not mean short-term coverage as defined in section 62A.65, new text end 7.14 new text begin subdivision 7. For purposes of this chapter, a health carrier shall not be deemed to be new text end 7.15 new text begin offering individual health plan coverage solely because the carrier maintains a conversion new text end 7.16 new text begin policy in connection with a group health plan. new text end 7.17 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for coverage effective on or after new text end 7.18 new text begin January 1, 2014. new text end 7.19    Sec. 9. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision 7.20to read: 7.21     new text begin Subd. 5. new text end new text begin Individual market. new text end new text begin "Individual market" means the market for health new text end 7.22 new text begin insurance coverage offered to individuals other than in connection with a group health plan. new text end 7.23 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 7.24    Sec. 10. Minnesota Statutes 2012, section 62A.011, is amended by adding a 7.25subdivision to read: 7.26     new text begin Subd. 6. new text end new text begin Minnesota Insurance Marketplace. new text end new text begin "Minnesota Insurance Marketplace" new text end 7.27 new text begin means the Minnesota Insurance Marketplace as defined in section 62V.02. new text end 7.28    Sec. 11. Minnesota Statutes 2012, section 62A.011, is amended by adding a 7.29subdivision to read: 7.30     new text begin Subd. 7. new text end new text begin Qualified health plan. new text end new text begin "Qualified health plan" means a health plan that new text end 7.31 new text begin meets the definition in section 1301(a) of the Affordable Care Act and has been certified new text end 8.1 new text begin by the board of the Minnesota Insurance Marketplace in accordance with chapter 62V to new text end 8.2 new text begin be offered through the Minnesota Insurance Marketplace. new text end 8.3    Sec. 12. Minnesota Statutes 2012, section 62A.02, is amended by adding a subdivision 8.4to read: 8.5     new text begin Subd. 8. new text end new text begin Filing by health carriers for purposes of complying with the new text end 8.6 new text begin certification requirements of the Minnesota Insurance Marketplace. new text end new text begin No qualified new text end 8.7 new text begin health plan shall be offered through the Minnesota Insurance Marketplace until its form new text end 8.8 new text begin and the premium rates pertaining to the form have been approved by the commissioner of new text end 8.9 new text begin commerce or health, as appropriate, and the health plan has been determined to comply new text end 8.10 new text begin with the certification requirements of the Minnesota Insurance Marketplace in accordance new text end 8.11 new text begin with an agreement between the commissioners of commerce and health and the Minnesota new text end 8.12 new text begin Insurance Marketplace. new text end 8.13 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for coverage effective on or after new text end 8.14 new text begin January 1, 2014. new text end 8.15    Sec. 13. Minnesota Statutes 2012, section 62A.03, subdivision 1, is amended to read: 8.16    Subdivision 1. Conditions. No policy of individual accident and sickness insurance 8.17may be delivered or issued for delivery to a person in this state unless: 8.18(1) Premium. The entire money and other considerations therefor are expressed 8.19therein. 8.20(2) Time effective. The time at which the insurance takes effect and terminates is 8.21expressed therein. 8.22(3) One person. It purports to insure only one person, except that a policy may 8.23insure, originally or by subsequent amendment, upon the application of an adult member 8.24of a family deemed the policyholder, any two or more eligible members of that family, 8.25including: 8.26(a) husband, 8.27(b) wife, 8.28(c) dependent children new text begin as described in sections 62A.302 and 62A.3021 new text end , new text begin or new text end 8.29(d) any children under a specified age of 19 years or less, or 8.30(e) new text begin (d) new text end any other person dependent upon the policyholder. 8.31(4) Appearance. The style, arrangement, and overall appearance of the policy give 8.32no undue prominence to any portion of the text and every printed portion of the text of the 8.33policy and of any endorsements or attached papers is plainly printed in light-face type 8.34of a style in general use. The type size must be uniform and not less than ten point with 9.1a lowercase unspaced alphabet length not less than 120 point. The "text" includes all 9.2printed matter except the name and address of the insurer, name or title of the policy, the 9.3brief description, if any, the reference to renewal or cancellation by a separate statement, 9.4if any, and the captions and subcaptions. 9.5(5) Description of policy. The policy, on the first page, indicates or refers to its 9.6provisions for renewal or cancellation either in the brief description, if any, or by a separate 9.7statement printed in type not smaller than the type used for captions or a separate provision 9.8bearing a caption which accurately describes the renewability or cancelability of the policy. 9.9(6) Exceptions in policy. The exceptions and reductions of indemnity are set 9.10forth in the policy and, except those which are set forth in section 62A.04, printed, at 9.11the insurer's option, either with the benefit provision to which they apply, or under an 9.12appropriate caption such as "EXCEPTIONS" or "EXCEPTIONS AND REDUCTIONS." 9.13However, if an exception or reduction specifically applies only to a particular benefit of 9.14the policy, a statement of the exception or reduction must be included with the benefit 9.15provision to which it applies. 9.16(7) Form number. Each form, including riders and endorsements, is identified by a 9.17form number in the lower left hand corner of the first page thereof. 9.18(8) No incorporation by reference. It contains no provision purporting to make 9.19any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy 9.20unless the portion is set forth in full in the policy, except in the case of the incorporation 9.21of, or reference to, a statement of rates, classification of risks, or short rate table filed 9.22with the commissioner. 9.23(9) Medical benefits. If the policy contains a provision for medical expense benefits, 9.24the term "medical benefits" or similar terms as used therein includes treatments by all 9.25licensed practitioners of the healing arts unless, subject to the qualifications contained in 9.26clause (10), the policy specifically states the practitioners whose services are covered. 9.27(10) Osteopath, optometrist, chiropractor, or registered nurse services. With 9.28respect to any policy of individual accident and sickness insurance issued or entered 9.29into subsequent to August 1, 1974, notwithstanding the provisions of the policy, if it 9.30contains a provision providing for reimbursement for any service which is in the lawful 9.31scope of practice of a duly licensed osteopath, optometrist, chiropractor, or registered 9.32nurse meeting the requirements of section 62A.15, subdivision 3a, the person entitled to 9.33benefits or person performing services under the policy is entitled to reimbursement on an 9.34equal basis for the service, whether the service is performed by a physician, osteopath, 9.35optometrist, chiropractor, or registered nurse meeting the requirements of section 62A.15, 9.36subdivision 3a , licensed under the laws of this state. 10.1 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 10.2    Sec. 14. Minnesota Statutes 2012, section 62A.04, subdivision 2, is amended to read: 10.3    Subd. 2. Required provisions. Except as provided in subdivision 4 each such 10.4policy delivered or issued for delivery to any person in this state shall contain the 10.5provisions specified in this subdivision in the words in which the same appear in this 10.6section. The insurer may, at its option, substitute for one or more of such provisions 10.7corresponding provisions of different wording approved by the commissioner which are 10.8in each instance not less favorable in any respect to the insured or the beneficiary. Such 10.9provisions shall be preceded individually by the caption appearing in this subdivision or, at 10.10the option of the insurer, by such appropriate individual or group captions or subcaptions 10.11as the commissioner may approve. 10.12(1) A provision as follows: 10.13ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and 10.14the attached papers, if any, constitutes the entire contract of insurance. No change in this 10.15policy shall be valid until approved by an executive officer of the insurer and unless such 10.16approval be endorsed hereon or attached hereto. No agent has authority to change this 10.17policy or to waive any of its provisions. 10.18(2) A provision as follows: 10.19TIME LIMIT ON CERTAIN DEFENSES: (a) After two years from the date of issue 10.20of this policy no misstatements, except fraudulent misstatements, made by the applicant 10.21in the application for such policy shall be used to void the policy or to deny a claim for 10.22loss incurred or disability (as defined in the policy) commencing after the expiration 10.23of such two year period. 10.24The foregoing policy provision shall not be so construed as to affect any legal 10.25requirement for avoidance of a policy or denial of a claim during such initial two year 10.26period, nor to limit the application of clauses (1), (2), (3), (4) and (5), in the event of 10.27misstatement with respect to age or occupation or other insurance. A policy which the 10.28insured has the right to continue in force subject to its terms by the timely payment of 10.29premium (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at 10.30least five years from its date of issue, may contain in lieu of the foregoing the following 10.31provisions (from which the clause in parentheses may be omitted at the insurer's option) 10.32under the caption "INCONTESTABLE": 10.33After this policy has been in force for a period of two years during the lifetime of 10.34the insured (excluding any period during which the insured is disabled), it shall become 10.35incontestable as to the statements contained in the application. 11.1(b) No claim for loss incurred or disability (as defined in the policy) commencing after 11.2two years from the date of issue of this policy shall be reduced or denied on the ground that 11.3a disease or physical condition not excluded from coverage by name or specific description 11.4effective on the date of loss had existed prior to the effective date of coverage of this policy. 11.5(3) new text begin (a) Except as required for qualified health plans sold through the Minnesota new text end 11.6 new text begin Insurance Marketplace to individuals receiving advance payments of the premium tax new text end 11.7 new text begin credit, new text end a provision as follows: 11.8GRACE PERIOD: A grace period of ..... (insert a number not less than "7" for 11.9weekly premium policies, "10" for monthly premium policies and "31" for all other 11.10policies) days will be granted for the payment of each premium falling due after the first 11.11premium, during which grace period the policy shall continue in force. 11.12A policy which contains a cancellation provision may add, at the end of the above 11.13provision, 11.14subject to the right of the insurer to cancel in accordance with the cancellation 11.15provision hereof. 11.16A policy in which the insurer reserves the right to refuse any renewal shall have, 11.17at the beginning of the above provision, 11.18Unless not less than five days prior to the premium due date the insurer has delivered 11.19to the insured or has mailed to the insured's last address as shown by the records of the 11.20insurer written notice of its intention not to renew this policy beyond the period for which 11.21the premium has been accepted. 11.22 new text begin (b) For qualified health plans sold through the Minnesota Insurance Marketplace new text end 11.23 new text begin to individuals receiving advance payments of the premium tax credit, a grace period new text end 11.24 new text begin provision must be included that complies with the Affordable Care Act and is no less new text end 11.25 new text begin restrictive than the grace period required by the Affordable Care Act. new text end 11.26(4) A provision as follows: 11.27REINSTATEMENT: If any renewal premium be not paid within the time granted the 11.28insured for payment, a subsequent acceptance of premium by the insurer or by any agent 11.29duly authorized by the insurer to accept such premium, without requiring in connection 11.30therewith an application for reinstatement, shall reinstate the policy. If the insurer or 11.31such agent requires an application for reinstatement and issues a conditional receipt for 11.32the premium tendered, the policy will be reinstated upon approval of such application 11.33by the insurer or, lacking such approval, upon the forty-fifth day following the date of 11.34such conditional receipt unless the insurer has previously notified the insured in writing 11.35of its disapproval of such application. For health plans described in section 62A.011, 11.36subdivision 3 , clause (10), an insurer must accept payment of a renewal premium and 12.1reinstate the policy, if the insured applies for reinstatement no later than 60 days after the 12.2due date for the premium payment, unless: 12.3(1) the insured has in the interim left the state or the insurer's service area; or 12.4(2) the insured has applied for reinstatement on two or more prior occasions. 12.5The reinstated policy shall cover only loss resulting from such accidental injury as 12.6may be sustained after the date of reinstatement and loss due to such sickness as may 12.7begin more than ten days after such date. In all other respects the insured and insurer shall 12.8have the same rights thereunder as they had under the policy immediately before the due 12.9date of the defaulted premium, subject to any provisions endorsed hereon or attached 12.10hereto in connection with the reinstatement. Any premium accepted in connection with 12.11a reinstatement shall be applied to a period for which premium has not been previously 12.12paid, but not to any period more than 60 days prior to the date of reinstatement. The last 12.13sentence of the above provision may be omitted from any policy which the insured has 12.14the right to continue in force subject to its terms by the timely payment of premiums 12.15(1) until at least age 50, or, (2) in the case of a policy issued after age 44, for at least 12.16five years from its date of issue. 12.17(5) A provision as follows: 12.18NOTICE OF CLAIM: Written notice of claim must be given to the insurer within 12.1920 days after the occurrence or commencement of any loss covered by the policy, or as 12.20soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or 12.21the beneficiary to the insurer at ..... (insert the location of such office as the insurer may 12.22designate for the purpose), or to any authorized agent of the insurer, with information 12.23sufficient to identify the insured, shall be deemed notice to the insurer. 12.24In a policy providing a loss-of-time benefit which may be payable for at least two 12.25years, an insurer may at its option insert the following between the first and second 12.26sentences of the above provision: 12.27Subject to the qualifications set forth below, if the insured suffers loss of time on 12.28account of disability for which indemnity may be payable for at least two years, the 12.29insured shall, at least once in every six months after having given notice of claim, give to 12.30the insurer notice of continuance of said disability, except in the event of legal incapacity. 12.31The period of six months following any filing of proof by the insured or any payment by 12.32the insurer on account of such claim or any denial of liability in whole or in part by the 12.33insurer shall be excluded in applying this provision. Delay in the giving of such notice 12.34shall not impair the insured's right to any indemnity which would otherwise have accrued 12.35during the period of six months preceding the date on which such notice is actually given. 12.36(6) A provision as follows: 13.1CLAIM FORMS: The insurer, upon receipt of a notice of claim, will furnish to the 13.2claimant such forms as are usually furnished by it for filing proofs of loss. If such forms 13.3are not furnished within 15 days after the giving of such notice the claimant shall be 13.4deemed to have complied with the requirements of this policy as to proof of loss upon 13.5submitting, within the time fixed in the policy for filing proofs of loss, written proof 13.6covering the occurrence, the character and the extent of the loss for which claim is made. 13.7(7) A provision as follows: 13.8PROOFS OF LOSS: Written proof of loss must be furnished to the insurer at its 13.9said office in case of claim for loss for which this policy provides any periodic payment 13.10contingent upon continuing loss within 90 days after the termination of the period for 13.11which the insurer is liable and in case of claim for any other loss within 90 days after the 13.12date of such loss. Failure to furnish such proof within the time required shall not invalidate 13.13nor reduce any claim if it was not reasonably possible to give proof within such time, 13.14provided such proof is furnished as soon as reasonably possible and in no event, except in 13.15the absence of legal capacity, later than one year from the time proof is otherwise required. 13.16(8) A provision as follows: 13.17TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for 13.18any loss other than loss for which this policy provides periodic payment will be paid 13.19immediately upon receipt of due written proof of such loss. Subject to due written proof 13.20of loss, all accrued indemnities for loss for which this policy provides periodic payment 13.21will be paid ..... (insert period for payment which must not be less frequently than 13.22monthly) and any balance remaining unpaid upon the termination of liability will be paid 13.23immediately upon receipt of due written proof. 13.24(9) A provision as follows: 13.25PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance 13.26with the beneficiary designation and the provisions respecting such payment which may 13.27be prescribed herein and effective at the time of payment. If no such designation or 13.28provision is then effective, such indemnity shall be payable to the estate of the insured. 13.29Any other accrued indemnities unpaid at the insured's death may, at the option of the 13.30insurer, be paid either to such beneficiary or to such estate. All other indemnities will 13.31be payable to the insured. 13.32The following provisions, or either of them, may be included with the foregoing 13.33provision at the option of the insurer: 13.34If any indemnity of this policy shall be payable to the estate of the insured, or to an 13.35insured or beneficiary who is a minor or otherwise not competent to give a valid release, 13.36the insurer may pay such indemnity, up to an amount not exceeding $..... (insert an amount 14.1which shall not exceed $1,000), to any relative by blood or connection by marriage of the 14.2insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any 14.3payment made by the insurer in good faith pursuant to this provision shall fully discharge 14.4the insurer to the extent of such payment. 14.5Subject to any written direction of the insured in the application or otherwise all 14.6or a portion of any indemnities provided by this policy on account of hospital, nursing, 14.7medical, or surgical services may, at the insurer's option and unless the insured requests 14.8otherwise in writing not later than the time of filing proofs of such loss, be paid directly to 14.9the hospital or person rendering such services; but it is not required that the service be 14.10rendered by a particular hospital or person. 14.11(10) A provision as follows: 14.12PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense 14.13shall have the right and opportunity to examine the person of the insured when and as 14.14often as it may reasonably require during the pendency of a claim hereunder and to make 14.15an autopsy in case of death where it is not forbidden by law. 14.16(11) A provision as follows: 14.17LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this 14.18policy prior to the expiration of 60 days after written proof of loss has been furnished in 14.19accordance with the requirements of this policy. No such action shall be brought after the 14.20expiration of three years after the time written proof of loss is required to be furnished. 14.21(12) A provision as follows: 14.22CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation 14.23of beneficiary, the right to change of beneficiary is reserved to the insured and the consent 14.24of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of 14.25this policy or to any change of beneficiary or beneficiaries, or to any other changes in 14.26this policy. The first clause of this provision, relating to the irrevocable designation of 14.27beneficiary, may be omitted at the insurer's option. 14.28 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 14.29    Sec. 15. Minnesota Statutes 2012, section 62A.047, is amended to read: 14.3062A.047 CHILDREN'S HEALTH SUPERVISION SERVICES AND 14.31PRENATAL CARE SERVICES. 14.32A policy of individual or group health and accident insurance regulated under this 14.33chapter, or individual or group subscriber contract regulated under chapter 62C, health 14.34maintenance contract regulated under chapter 62D, or health benefit certificate regulated 15.1under chapter 64B, issued, renewed, or continued to provide coverage to a Minnesota 15.2resident, must provide coverage for child health supervision services and prenatal care 15.3services. The policy, contract, or certificate must specifically exempt reasonable and 15.4customary charges for child health supervision services and prenatal care services from a 15.5deductible, co-payment, or other coinsurance or dollar limitation requirement. Nothing 15.6in this section prohibits a health carrier that has a network of providers from imposing 15.7a deductible, co-payment, or other coinsurance or dollar limitation requirement for 15.8child health supervision services and prenatal care services that are delivered by an 15.9out-of-network provider. This section does not prohibit the use of policy waiting periods 15.10or preexisting condition limitations for these services. Minimum benefits may be limited 15.11to one visit payable to one provider for all of the services provided at each visit cited in 15.12this section subject to the schedule set forth in this section. Nothing in this section applies 15.13to a policy designed primarily to provide coverage payable on a per diem, fixed indemnity, 15.14or non-expense-incurred basis, or a policy that provides only accident coverage. new text begin A policy, new text end 15.15 new text begin contract, or certificate described under this section may not apply to preexisting condition new text end 15.16 new text begin limitations to individuals under 19 years of age. This section does not apply to individual new text end 15.17 new text begin coverage under a grandfathered plan. new text end 15.18"Child health supervision services" means pediatric preventive services, appropriate 15.19immunizations, developmental assessments, and laboratory services appropriate to the age 15.20of a child from birth to age six, and appropriate immunizations from ages six to 18, as 15.21defined by Standards of Child Health Care issued by the American Academy of Pediatrics. 15.22Reimbursement must be made for at least five child health supervision visits from birth 15.23to 12 months, three child health supervision visits from 12 months to 24 months, once a 15.24year from 24 months to 72 months. 15.25"Prenatal care services" means the comprehensive package of medical and 15.26psychosocial support provided throughout the pregnancy, including risk assessment, 15.27serial surveillance, prenatal education, and use of specialized skills and technology, 15.28when needed, as defined by Standards for Obstetric-Gynecologic Services issued by the 15.29American College of Obstetricians and Gynecologists. 15.30 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 15.31    Sec. 16. Minnesota Statutes 2012, section 62A.049, is amended to read: 15.3262A.049 LIMITATION ON PREAUTHORIZATIONS; EMERGENCIES. 15.33No policy of accident and sickness insurance or group subscriber contract regulated 15.34under chapter 62C issued or renewed in this state may contain a provision that makes an 16.1insured person ineligible to receive full benefits because of the insured's failure to obtain 16.2preauthorization, if that failure occurs because of the need for emergency confinement 16.3or emergency treatment. The insured or an authorized representative of the insured shall 16.4notify the insurer as soon after the beginning of emergency confinement or emergency 16.5treatment as reasonably possible. However, to the extent that the insurer suffers actual 16.6prejudice caused by the failure to obtain preauthorization, the insured may be denied all or 16.7part of the insured's benefits. This provision does not apply to admissions for treatment of 16.8chemical dependency and nervous and mental disorders. 16.9 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 16.10    Sec. 17. Minnesota Statutes 2012, section 62A.136, is amended to read: 16.1162A.136 HEARING, DENTAL, AND VISION PLAN COVERAGE. 16.12The following provisions do not apply to health plans as defined in section 62A.011, 16.13subdivision 3 , clause (6), providing hearing, dental, or vision coverage only: sections 16.1462A.041 ; 62A.0411; 62A.047; 62A.149; 62A.151; 62A.152; 62A.154; 62A.155; 62A.17, 16.15subdivision 6 ; 62A.21, subdivision 2b; 62A.26; 62A.28; 62A.285; 62A.30; 62A.304; new text begin and new text end 16.16 62A.3093; and . 16.17 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 16.18    Sec. 18. Minnesota Statutes 2012, section 62A.149, subdivision 1, is amended to read: 16.19    Subdivision 1. Application. The provisions of this section apply to all group 16.20policies of accident and health insurance and group subscriber contracts offered by 16.21nonprofit health service plan corporations regulated under chapter 62C, and to a plan or 16.22policy that is individually underwritten or provided for a specific individual and family 16.23members as a nongroup policy unless the individual elects in writing to refuse benefits 16.24under this subdivision in exchange for an appropriate reduction in premiums or subscriber 16.25charges under the policy or plan, when the policies or subscriber contracts are issued or 16.26delivered in Minnesota or provide benefits to Minnesota residents enrolled thereunder. 16.27    This section does not apply to policies designed primarily to provide coverage 16.28payable on a per diem, fixed indemnity or nonexpense incurred basis or policies that 16.29provide accident only coverage. 16.30    Every insurance policy or subscriber contract included within the provisions of this 16.31subdivision, upon issuance or renewal, shall provide coverage that complies with the 16.32requirements of section 62Q.47, paragraphs (b) and (c), for the treatment of alcoholism, 16.33chemical dependency or drug addiction to any Minnesota resident entitled to coverage. 17.1 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 17.2    Sec. 19. Minnesota Statutes 2012, section 62A.17, subdivision 2, is amended to read: 17.3    Subd. 2. Responsibility of employee. Every covered employee electing to continue 17.4coverage shall pay the former employer, on a monthly basis, the cost of the continued 17.5coverage. The policy, contract, or plan must require the group policyholder or contract 17.6holder to, upon request, provide the employee with written verification from the insurer 17.7of the cost of this coverage promptly at the time of eligibility for this coverage and at 17.8any time during the continuation period. If the policy, contract, or health care plan is 17.9administered by a trust, every covered employee electing to continue coverage shall pay 17.10the trust the cost of continued coverage according to the eligibility rules established by the 17.11trust. In no event shall the amount of premium charged exceed 102 percent of the cost 17.12to the plan for such period of coverage for similarly situated employees with respect to 17.13whom neither termination nor layoff has occurred, without regard to whether such cost 17.14is paid by the employer or employee. The employee shall be eligible to continue the 17.15coverage until the employee becomes covered under another group health plan, or for a 17.16period of 18 months after the termination of or lay off from employment, whichever is 17.17shorter. new text begin For an individual age 19 or older, new text end if the employee becomes covered under another 17.18group policy, contract, or health plan and the new group policy, contract, or health plan 17.19contains any preexisting condition limitations, the employee may, subject to the 18-month 17.20maximum continuation limit, continue coverage with the former employer until the 17.21preexisting condition limitations have been satisfied. The new policy, contract, or health 17.22plan is primary except as to the preexisting condition. In the case of a newborn child who 17.23is a dependent of the employee, the new policy, contract, or health plan is primary upon 17.24the date of birth of the child, regardless of which policy, contract, or health plan coverage 17.25is deemed primary for the mother of the child. 17.26 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 17.27    Sec. 20. Minnesota Statutes 2012, section 62A.17, subdivision 6, is amended to read: 17.28    Subd. 6. Conversion to individual policy. A group insurance policy that provides 17.29posttermination or layoff coverage as required by this section shall also include a 17.30provision allowing a covered employee, surviving spouse, or dependent at the expiration 17.31of the posttermination or layoff coverage provided by subdivision 2 to obtain from the 17.32insurer offering the group policy or group subscriber contract, at the employee's, spouse's, 17.33or dependent's option and expense, without further evidence of insurability and without 17.34interruption of coverage, an individual policy of insurance or an individual subscriber 18.1contract providing at least the minimum benefits of a qualified plan as prescribed by 18.2section and the option of a number three qualified plan, a number two qualified 18.3plan, and a number one qualified plan as provided by section , subdivisions 1 to 18.43, provided application is made to the insurer within 30 days following notice of the 18.5expiration of the continued coverage and upon payment of the appropriate premium. 18.6The required conversion contract must treat pregnancy the same as any other covered 18.7illness under the conversion contract. A health maintenance contract issued by a health 18.8maintenance organization that provides posttermination or layoff coverage as required 18.9by this section shall also include a provision allowing a former employee, surviving 18.10spouse, or dependent at the expiration of the posttermination or layoff coverage provided 18.11in subdivision 2 to obtain from the health maintenance organization, at the former 18.12employee's, spouse's, or dependent's option and expense, without further evidence of 18.13insurability and without interruption of coverage, an individual health maintenance 18.14contract. Effective January 1, 1985, enrollees who have become nonresidents of the health 18.15maintenance organization's service area shall be given the option, to be arranged by the 18.16health maintenance organization, of a number three qualified plan, a number two qualified 18.17plan, or a number one qualified plan as provided by section , subdivisions 1 to 3. 18.18This option shall be made available at the enrollee's expense, without further evidence of 18.19insurability and without interruption of coverage. 18.20A policy providing reduced benefits at a reduced premium rate may be accepted 18.21by the employee, the spouse, or a dependent in lieu of the optional coverage otherwise 18.22required by this subdivision. 18.23The new text begin An new text end individual policy or contract new text begin issued as a conversion policy prior to January new text end 18.24 new text begin 1, 2014, new text end shall be renewable at the option of the individual as long as the individual is not 18.25covered under another qualified plan as defined in section 62E.02, subdivision 4. Any 18.26revisions in the table of rate for the individual policy shall apply to the covered person's 18.27original age at entry and shall apply equally to all similar new text begin conversion new text end policies issued 18.28by the insurer. 18.29 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 18.30    Sec. 21. Minnesota Statutes 2012, section 62A.21, subdivision 2b, is amended to read: 18.31    Subd. 2b. Conversion privilege. Every policy described in subdivision 1 shall 18.32contain a provision allowing a former spouse and dependent children of an insured, 18.33without providing evidence of insurability, to obtain from the insurer at the expiration of 18.34any continuation of coverage required under subdivision 2a or sections and 18.35, conversion coverage providing at least the minimum benefits of a qualified 19.1plan as prescribed by section and the option of a number three qualified plan, a 19.2number two qualified plan, a number one qualified plan as provided by section , 19.3subdivisions 1 to 3, provided application is made to the insurer within 30 days following 19.4notice of the expiration of the continued coverage and upon payment of the appropriate 19.5premium. The new text begin An new text end individual policy new text begin or contract issued as a conversion policy prior to new text end 19.6 new text begin January 1, 2014, new text end shall be renewable at the option of the covered person as long as the 19.7covered person is not covered under another qualified plan as defined in section 62E.02, 19.8subdivision 4 . Any revisions in the table of rate for the individual policy shall apply to the 19.9covered person's original age at entry and shall apply equally to all similar new text begin conversion new text end 19.10 policies issued by the insurer. 19.11A policy providing reduced benefits at a reduced premium rate may be accepted by 19.12the covered person in lieu of the optional coverage otherwise required by this subdivision. 19.13 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 19.14    Sec. 22. Minnesota Statutes 2012, section 62A.28, subdivision 2, is amended to read: 19.15    Subd. 2. Required coverage. Every policy, plan, certificate, or contract referred to 19.16in subdivision 1 issued or renewed after August 1, 1987, must provide coverage for scalp 19.17hair prostheses worn for hair loss suffered as a result of alopecia areata. 19.18The coverage required by this section is subject to the co-payment, coinsurance, 19.19deductible, and other enrollee cost-sharing requirements that apply to similar types of 19.20items under the policy, plan, certificate, or contract, and is limited to a maximum of $350 19.21in any benefit year new text begin and may be limited to one prosthesis per benefit year new text end . 19.22 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 19.23    Sec. 23. Minnesota Statutes 2012, section 62A.302, is amended to read: 19.2462A.302 COVERAGE OF DEPENDENTS. 19.25    Subdivision 1. Scope of coverage. This section applies to: 19.26(1) a health plan as defined in section 62A.011; new text begin and new text end 19.27(2) coverage described in section 62A.011, subdivision 3, clauses (4), (6), (7), (8), 19.28(9), and (10); and 19.29(3) new text begin (2) new text end a policy, contract, or certificate issued by a community integrated service 19.30network licensed under chapter 62N. 19.31    Subd. 2. Required coverage. Every health plan included in subdivision 1 that 19.32provides dependent coverage must define "dependent" no more restrictively than the 19.33definition provided in section 62L.02 new text begin , subdivision 11 new text end . 20.1     new text begin Subd. 3. new text end new text begin No additional restrictions permitted. new text end new text begin Any health plan included in new text end 20.2 new text begin subdivision 1 that provides dependent coverage of children shall make that coverage new text end 20.3 new text begin available to children until the child attains 26 years of age. A health carrier must not place new text end 20.4 new text begin restrictions on this coverage and must comply with the following requirements: new text end 20.5 new text begin (1) with respect to a child who has not attained 26 years of age, a health carrier shall new text end 20.6 new text begin not define dependent for purposes of eligibility for dependent coverage of children other new text end 20.7 new text begin than the terms of a relationship between a child and the enrollee or spouse of the enrollee; new text end 20.8 new text begin (2) a health carrier must not deny or restrict coverage for a child who has not attained new text end 20.9 new text begin 26 years of age based on (i) the presence or absence of the child's financial dependency upon new text end 20.10 new text begin the participant, primary subscriber, or any other person; (ii) residency with the participant new text end 20.11 new text begin and in the individual market the primary subscriber, or with any other person; (iii) marital new text end 20.12 new text begin status; (iv) student status; (v) employment; or (vi) any combination of those factors; and new text end 20.13 new text begin (3) a health carrier must not deny or restrict coverage of a child based on eligibility new text end 20.14 new text begin for other coverage, except as provided in subdivision 5. new text end 20.15     new text begin Subd. 4. new text end new text begin Grandchildren. new text end new text begin Nothing in this section requires a health carrier to make new text end 20.16 new text begin coverage available for a grandchild, unless the grandparent becomes the legal guardian new text end 20.17 new text begin or adoptive parent of that grandchild or unless the grandchild meets the requirements new text end 20.18 new text begin of section 62A.042. For grandchildren included under a grandparent's policy pursuant new text end 20.19 new text begin to section 62A.042, coverage for the grandchild may terminate if the grandchild does new text end 20.20 new text begin not continue to reside with the covered grandparent continuously from birth, if the new text end 20.21 new text begin grandchild does not remain financially dependent upon the covered grandparent, or when new text end 20.22 new text begin the grandchild reaches age 25, except as provided in section 62A.14 or if coverage is new text end 20.23 new text begin continued under section 62A.20. new text end 20.24     new text begin Subd. 5. new text end new text begin Terms of coverage of dependents. new text end new text begin The terms of coverage in a health plan new text end 20.25 new text begin offered by a health carrier providing dependent coverage of children cannot vary based on new text end 20.26 new text begin age except for children who are 26 years of age or older. new text end 20.27     new text begin Subd. 6. new text end new text begin Opportunity to enroll. new text end new text begin A health carrier must comply with all provisions new text end 20.28 new text begin of the Affordable Care Act in regards to providing an opportunity to enroll in coverage to new text end 20.29 new text begin any child whose coverage ended, or was not eligible for coverage under a group health new text end 20.30 new text begin plan or individual health plan because, under the terms of the coverage, the availability of new text end 20.31 new text begin dependent coverage of a child ended before age 26. new text end 20.32     new text begin Subd. 7. new text end new text begin Grandfathered plan coverage. new text end new text begin (a) For plan years beginning before new text end 20.33 new text begin January 1, 2014, a group health plan that is a grandfathered plan and makes available new text end 20.34 new text begin dependent coverage of children may exclude an adult child who has not attained 26 new text end 20.35 new text begin years of age from coverage only if the adult child is eligible to enroll in an eligible new text end 21.1 new text begin employer-sponsored health benefit plan, as defined in section 5000A(f)(2) of the Internal new text end 21.2 new text begin Revenue Code, other than the group health plan of a parent. new text end 21.3 new text begin (b) For plan years beginning on or after January 1, 2014, a group health plan that is a new text end 21.4 new text begin grandfathered plan must comply with all requirements of this section. new text end 21.5     new text begin Subd. 8. new text end new text begin Compliance. new text end new text begin This section does not require compliance with any provision new text end 21.6 new text begin of the Affordable Care Act before the effective date provided for that provision in the new text end 21.7 new text begin Affordable Care Act. new text end 21.8     new text begin Subd. 9. new text end new text begin Enforcement. new text end new text begin The commissioner shall enforce this section. new text end 21.9 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 21.10    Sec. 24. new text begin [62A.3021] COVERAGE OF DEPENDENTS BY PLANS OTHER THAN new text end 21.11 new text begin HEALTH PLANS. new text end 21.12     new text begin Subdivision 1. new text end new text begin Scope of coverage. new text end new text begin This section applies to coverage described in new text end 21.13 new text begin section 62A.011, subdivision 3, clauses (4), (6), (7), (8), (9), and (10). new text end 21.14     new text begin Subd. 2. new text end new text begin Dependent. new text end new text begin "Dependent" means an eligible employee's spouse, unmarried new text end 21.15 new text begin child who is under the age of 25, dependent child of any age who is disabled and who new text end 21.16 new text begin meets the eligibility criteria in section 62A.14, subdivision 2, or any other person whom new text end 21.17 new text begin state or federal law requires to be treated as a dependent for purposes of health plans. For new text end 21.18 new text begin the purpose of this definition, a child includes a child for whom the employee or the new text end 21.19 new text begin employee's spouse has been appointed legal guardian and an adoptive child as provided in new text end 21.20 new text begin section 62A.27. A child also includes grandchildren as provided in section 62A.042 with new text end 21.21 new text begin continued eligibility of grandchildren as provided in section 62A.302, subdivision 4. new text end 21.22 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 21.23    Sec. 25. Minnesota Statutes 2012, section 62A.615, is amended to read: 21.2462A.615 PREEXISTING CONDITIONS DISCLOSED AT TIME OF 21.25APPLICATION. 21.26No insurer may cancel or rescind a health insurance policy for a preexisting condition 21.27of which the application or other information provided by the insured reasonably gave 21.28the insurer notice. No insurer may restrict coverage for a preexisting condition of which 21.29the application or other information provided by the insured reasonably gave the insurer 21.30notice unless the coverage is restricted at the time the policy is issued and the restriction is 21.31disclosed in writing to the insured at the time the policy is issued. new text begin In addition, no health plan new text end 21.32 new text begin may restrict coverage for a preexisting condition for an individual who is under 19 years new text end 21.33 new text begin of age. This section does not apply to individual health plans that are grandfathered plans. new text end 22.1 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 22.2    Sec. 26. Minnesota Statutes 2012, section 62A.65, subdivision 3, is amended to read: 22.3    Subd. 3. Premium rate restrictions. No individual health plan may be offered, 22.4sold, issued, or renewed to a Minnesota resident unless the premium rate charged is 22.5determined in accordance with the following requirements: 22.6(a) Premium rates must be no more than 25 percent above and no more than 25 22.7percent below the index rate charged to individuals for the same or similar coverage, 22.8adjusted pro rata for rating periods of less than one year. The premium variations 22.9permitted by this paragraph must be based only upon health status, claims experience, 22.10and occupation. For purposes of this paragraph, health status includes refraining from 22.11tobacco use or other actuarially valid lifestyle factors associated with good health, 22.12provided that the lifestyle factor and its effect upon premium rates have been determined 22.13by the commissioner to be actuarially valid and have been approved by the commissioner. 22.14Variations permitted under this paragraph must not be based upon age or applied 22.15differently at different ages. This paragraph does not prohibit use of a constant percentage 22.16adjustment for factors permitted to be used under this paragraph. 22.17(b) new text begin (a) new text end Premium rates may vary based upon the ages of covered persons only as 22.18provided in this paragraph. In addition to the variation permitted under paragraph (a), each 22.19health carrier may use an additional premium variation based upon age of up to plus or 22.20minus 50 percent of the index rate new text begin in accordance with the provisions of the Affordable new text end 22.21 new text begin Care Act new text end . 22.22(c) A health carrier may request approval by the commissioner to establish separate 22.23geographic regions determined by the health carrier and to establish separate index rates 22.24for each such region. 22.25 new text begin (b) Premium rates may vary based upon geographic rating area. new text end The commissioner 22.26shall grant approval if the following conditions are met: 22.27(1) the geographic regions must be applied uniformly by the health carrier new text begin the areas new text end 22.28 new text begin are established in accordance with the Affordable Care Act new text end ; 22.29(2) each geographic region must be composed of no fewer than seven counties that 22.30create a contiguous region; and 22.31(3) the health carrier provides actuarial justification acceptable to the commissioner 22.32for the proposed geographic variations in index rates new text begin premium rates for each area new text end , 22.33establishing that the variations are based upon differences in the cost to the health carrier 22.34of providing coverage. 23.1(d) Health carriers may use rate cells and must file with the commissioner the rate 23.2cells they use. Rate cells must be based upon the number of adults or children covered 23.3under the policy and may reflect the availability of Medicare coverage. The rates for 23.4different rate cells must not in any way reflect generalized differences in expected costs 23.5between principal insureds and their spouses. 23.6 new text begin (c) Premium rates may vary based upon tobacco use, in accordance with the new text end 23.7 new text begin provisions of the Affordable Care Act. new text end 23.8(e) new text begin (d) new text end In developing its index rates and premiums for a health plan, a health carrier 23.9shall take into account only the following factors: 23.10(1) actuarially valid differences in rating factors permitted under paragraphs (a) 23.11and (b) new text begin (c) new text end ; and 23.12(2) actuarially valid geographic variations if approved by the commissioner as 23.13provided in paragraph (c) new text begin (b) new text end . 23.14 new text begin (e) The premium charged with respect to any particular individual health plan shall new text end 23.15 new text begin not be adjusted more frequently than annually or January 1 of the year following initial new text end 23.16 new text begin enrollment, except that the premium rates may be changed to reflect: new text end 23.17 new text begin (1) changes to the family composition of the policyholder; new text end 23.18 new text begin (2) changes in geographic rating area of the policyholder, as provided in paragraph new text end 23.19 new text begin (b); new text end 23.20 new text begin (3) changes in age, as provided in paragraph (a); new text end 23.21 new text begin (4) changes in tobacco use, as provided in paragraph (c); new text end 23.22 new text begin (5) transfer to a new health plan requested by the policyholder; or new text end 23.23 new text begin (6) other changes required by or otherwise expressly permitted by state or federal new text end 23.24 new text begin law or regulations. new text end 23.25(f) All premium variations must be justified in initial rate filings and upon request of 23.26the commissioner in rate revision filings. All rate variations are subject to approval by 23.27the commissioner. 23.28(g) The loss ratio must comply with the section 62A.021 requirements for individual 23.29health plans. 23.30(h) The rates must not be approved, unless the commissioner has determined that the 23.31rates are reasonable. In determining reasonableness, the commissioner shall consider the 23.32growth rates applied under section 62J.04, subdivision 1, paragraph (b), to the calendar 23.33year or years that the proposed premium rate would be in effect, new text begin and new text end actuarially valid 23.34changes in risks associated with the enrollee populations, and actuarially valid changes as 23.35a result of statutory changes in Laws 1992, chapter 549. 24.1(i) An insurer new text begin A health carrier new text end may, as part of a minimum lifetime loss ratio 24.2guarantee filing under section 62A.02, subdivision 3a, include a rating practices guarantee 24.3as provided in this paragraph. The rating practices guarantee must be in writing and 24.4must guarantee that the policy form will be offered, sold, issued, and renewed only with 24.5premium rates and premium rating practices that comply with subdivisions 2, 3, 4, and 5. 24.6The rating practices guarantee must be accompanied by an actuarial memorandum that 24.7demonstrates that the premium rates and premium rating system used in connection with 24.8the policy form will satisfy the guarantee. The guarantee must guarantee refunds of any 24.9excess premiums to policyholders charged premiums that exceed those permitted under 24.10subdivision 2, 3, 4, or 5. An insurer new text begin A health carrier new text end that complies with this paragraph in 24.11connection with a policy form is exempt from the requirement of prior approval by the 24.12commissioner under paragraphs (c) new text begin (b) new text end , (f), and (h). 24.13 new text begin (j) The commissioner may establish regulations to implement the provisions of new text end 24.14 new text begin this subdivision. new text end 24.15 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 24.16    Sec. 27. Minnesota Statutes 2012, section 62A.65, is amended by adding a subdivision 24.17to read: 24.18     new text begin Subd. 3a. new text end new text begin Disclosure. new text end new text begin (a) In connection with the offering for sale of a health plan new text end 24.19 new text begin in the individual market, a health carrier shall make a reasonable disclosure, as part of new text end 24.20 new text begin its solicitation and sales materials, of all of the following: new text end 24.21 new text begin (1) the provisions of the coverage concerning the health carrier's right to change new text end 24.22 new text begin premium rates and the factors that may affect changes in premium rates; and new text end 24.23 new text begin (2) a listing of and descriptive information, including benefits and premiums, about new text end 24.24 new text begin all individual health plans actively marketed by the health carrier and the availability of new text end 24.25 new text begin the individual health plans for which the individual is qualified. new text end 24.26 new text begin (b) Paragraph (a), clause (1), may be satisfied by referring individuals to the Health new text end 24.27 new text begin and Human Services Web portal, as defined under the Affordable Care Act. new text end 24.28    Sec. 28. Minnesota Statutes 2012, section 62A.65, is amended by adding a subdivision 24.29to read: 24.30     new text begin Subd. 3b. new text end new text begin Single risk pool. new text end new text begin A health carrier shall consider all enrollees in all health new text end 24.31 new text begin plans, other than short-term and grandfathered plan coverage, offered by the health carrier new text end 24.32 new text begin in the individual market, including those enrollees who enroll in qualified health plans new text end 24.33 new text begin offered through the Minnesota Insurance Marketplace, to be members of a single risk pool. new text end 25.1    Sec. 29. Minnesota Statutes 2012, section 62A.65, subdivision 5, is amended to read: 25.2    Subd. 5. Portability and conversion of coverage. (a) new text begin For plan years beginning new text end 25.3 new text begin on or after January 1, 2014, new text end no individual health plan may be offered, sold, issued, or 25.4with respect to children age 18 or under renewed, to a Minnesota resident that contains a 25.5preexisting condition limitation, preexisting condition exclusion, or exclusionary rider, 25.6unless the limitation or exclusion is permitted under this subdivision and under chapter 25.762L, provided that, except for children age 18 or under, underwriting restrictions may 25.8be retained on individual contracts that are issued without evidence of insurability as a 25.9replacement for prior individual coverage that was sold before May 17, 1993. The new text begin An new text end 25.10 individual new text begin age 19 or older new text end may be subjected to an 18-month preexisting condition limitation 25.11 new text begin during plan years beginning prior to January 1, 2014 new text end , unless the individual has maintained 25.12continuous coverage as defined in section 62L.02. The individual must not be subjected to 25.13an exclusionary rider. new text begin During plan years beginning prior to January 1, 2014, new text end an individual 25.14who new text begin is age 19 or older and who new text end has maintained continuous coverage may be subjected to a 25.15onetime preexisting condition limitation of up to 12 months, with credit for time covered 25.16under qualifying coverage as defined in section 62L.02, at the time that the individual first 25.17is covered under an individual health plan by any health carrier. Credit must be given for 25.18all qualifying coverage with respect to all preexisting conditions, regardless of whether 25.19the conditions were preexisting with respect to any previous qualifying coverage. The 25.20individual must not be subjected to an exclusionary rider. Thereafter, the individual new text begin who is new text end 25.21 new text begin age 19 or older new text end must not be subject to any preexisting condition limitation, preexisting 25.22condition exclusion, or exclusionary rider under an individual health plan by any health 25.23carrier, except an unexpired portion of a limitation under prior coverage, so long as the 25.24individual maintains continuous coverage as defined in section 62L.02. new text begin The prohibition on new text end 25.25 new text begin preexisting condition limitations for children age 18 or under does not apply to individual new text end 25.26 new text begin health plans that are grandfathered plans. The prohibition on preexisting condition new text end 25.27 new text begin limitations for adults age 19 and over beginning for plan years on or after January 1, 2014, new text end 25.28 new text begin does not apply to individual health plans that are grandfathered plans. new text end 25.29(b) A health carrier must offer an individual health plan to any individual previously 25.30covered under a group health plan issued by that health carrier, regardless of the size of 25.31the group, so long as the individual maintained continuous coverage as defined in section 25.3262L.02 . If the individual has available any continuation coverage provided under sections 25.3362A.146 ; 62A.148; 62A.17, subdivisions 1 and 2; 62A.20; 62A.21; 62C.142; 62D.101; or 25.3462D.105 , or continuation coverage provided under federal law, the health carrier need not 25.35offer coverage under this paragraph until the individual has exhausted the continuation 25.36coverage. The offer must not be subject to underwriting, except as permitted under this 26.1paragraph. A health plan issued under this paragraph must be a qualified plan as defined 26.2in section 62E.02 and must not contain any preexisting condition limitation, preexisting 26.3condition exclusion, or exclusionary rider, except for any unexpired limitation or 26.4exclusion under the previous coverage. The individual health plan must cover pregnancy 26.5on the same basis as any other covered illness under the individual health plan. The offer 26.6of coverage by the health carrier must inform the individual that the coverage, including 26.7what is covered and the health care providers from whom covered care may be obtained, 26.8may not be the same as the individual's coverage under the group health plan. The offer 26.9of coverage by the health carrier must also inform the individual that the individual, if 26.10a Minnesota resident, may be eligible to obtain coverage from (i) other private sources 26.11of health coverage, or (ii) the Minnesota Comprehensive Health Association, without a 26.12preexisting condition limitation, and must provide the telephone number used by that 26.13association for enrollment purposes. The initial premium rate for the individual health 26.14plan must comply with subdivision 3. The premium rate upon renewal must comply with 26.15subdivision 2. In no event shall the premium rate exceed 100 percent of the premium 26.16charged for comparable individual coverage by the Minnesota Comprehensive Health 26.17Association, and the premium rate must be less than that amount if necessary to otherwise 26.18comply with this section. An individual health plan offered under this paragraph to a 26.19person satisfies the health carrier's obligation to offer conversion coverage under section 26.20, with respect to that person. Coverage issued under this paragraph must provide 26.21that it cannot be canceled or nonrenewed as a result of the health carrier's subsequent 26.22decision to leave the individual, small employer, or other group market. Section 72A.20, 26.23subdivision 28 , applies to this paragraph. 26.24 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment, new text end 26.25 new text begin except that the amendment to paragraph (b) is effective January 1, 2014. new text end 26.26    Sec. 30. Minnesota Statutes 2012, section 62A.65, subdivision 6, is amended to read: 26.27    Subd. 6. Guaranteed issue not required. new text begin (a) new text end Nothing in this section requires a 26.28health carrier to initially issue a health plan to a Minnesota resident new text begin who is age 19 or older new text end 26.29 new text begin on the date the health plan becomes effective if the effective date is prior to January 1, new text end 26.30 new text begin 2014 new text end , except as otherwise expressly provided in subdivision 4 or 5. 26.31 new text begin (b) Guaranteed issue is required for all health plans, except grandfathered plans, new text end 26.32 new text begin beginning January 1, 2014. new text end 26.33 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 27.1    Sec. 31. Minnesota Statutes 2012, section 62A.65, subdivision 7, is amended to read: 27.2    Subd. 7. Short-term coverage. (a) For purposes of this section, "short-term 27.3coverage" means an individual health plan that: 27.4(1) is issued to provide coverage for a period of 185 days or less, except that the 27.5health plan may permit coverage to continue until the end of a period of hospitalization 27.6for a condition for which the covered person was hospitalized on the day that coverage 27.7would otherwise have ended; 27.8(2) is nonrenewable, provided that the health carrier may provide coverage for one or 27.9more subsequent periods that satisfy clause (1), if the total of the periods of coverage do not 27.10exceed a total of 365 days out of any 555-day period, plus any additional days covered as a 27.11result of hospitalization on the day that a period of coverage would otherwise have ended; 27.12(3) does not cover any preexisting conditions, including ones that originated during 27.13a previous identical policy or contract with the same health carrier where coverage was 27.14continuous between the previous and the current policy or contract; and 27.15(4) is available with an immediate effective date without underwriting upon receipt 27.16of a completed application indicating eligibility under the health carrier's eligibility 27.17requirements, provided that coverage that includes optional benefits may be offered on a 27.18basis that does not meet this requirement. 27.19(b) Short-term coverage is not subject to subdivisions 2 and 5. Short-term coverage 27.20may exclude as a preexisting condition any injury, illness, or condition for which the 27.21covered person had medical treatment, symptoms, or any manifestations before the 27.22effective date of the coverage, but dependent children born or placed for adoption during 27.23the policy period must not be subject to this provision. 27.24(c) Notwithstanding subdivision 3, and section 62A.021, a health carrier may 27.25combine short-term coverage with its most commonly sold individual qualified plan, as 27.26defined in section 62E.02, other than short-term coverage, for purposes of complying 27.27with the loss ratio requirement. 27.28(d) The 365-day coverage limitation provided in paragraph (a) applies to the total 27.29number of days of short-term coverage that covers a person, regardless of the number of 27.30policies, contracts, or health carriers that provide the coverage. A written application for 27.31short-term coverage must ask the applicant whether the applicant has been covered by 27.32short-term coverage by any health carrier within the 555 days immediately preceding the 27.33effective date of the coverage being applied for. Short-term coverage issued in violation 27.34of the 365-day limitation is valid until the end of its term and does not lose its status as 27.35short-term coverage, in spite of the violation. A health carrier that knowingly issues 27.36short-term coverage in violation of the 365-day limitation is subject to the administrative 28.1penalties otherwise available to the commissioner of commerce or the commissioner 28.2of health, as appropriate. 28.3(e) Time spent under short-term coverage counts as time spent under a preexisting 28.4condition limitation for purposes of group or individual health plans, other than short-term 28.5coverage, subsequently issued to that person, or to cover that person, by any health carrier, 28.6if the person maintains continuous coverage as defined in section . Short-term 28.7coverage is a health plan and is qualifying coverage as defined in section . 28.8Notwithstanding any other law to the contrary, a health carrier is not required under any 28.9circumstances to provide a person covered by short-term coverage the right to obtain 28.10coverage on a guaranteed issue basis under another health plan offered by the health 28.11carrier, as a result of the person's enrollment in short-term coverage. 28.12 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 28.13    Sec. 32. Minnesota Statutes 2012, section 62C.14, subdivision 5, is amended to read: 28.14    Subd. 5. Disabled dependents. A subscriber's individual contract or any group 28.15contract delivered or issued for delivery in this state and providing that coverage of 28.16a dependent child of the subscriber or a dependent child of a covered group member 28.17shall terminate upon attainment of a specified new text begin limiting new text end age new text begin as defined in section 62Q.01, new text end 28.18 new text begin subdivision 9, new text end shall also provide in substance that attainment of that age shall not terminate 28.19coverage while the child is (a) incapable of self-sustaining employment by reason of 28.20developmental disability, mental illness or disorder, or physical disability, and (b) chiefly 28.21dependent upon the subscriber or employee for support and maintenance, provided proof 28.22of incapacity and dependency is furnished by the subscriber within 31 days of attainment 28.23of the new text begin limiting new text end age new text begin as defined in section 62Q.01, subdivision 9 new text end , and subsequently as 28.24required by the corporation, but not more frequently than annually after a two-year period 28.25following attainment of the age. Any notice regarding termination of coverage due to 28.26attainment of the limiting age must include information about this provision. 28.27 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 28.28    Sec. 33. Minnesota Statutes 2012, section 62C.142, subdivision 2, is amended to read: 28.29    Subd. 2. Conversion privilege. Every subscriber contract, other than a contract 28.30whose continuance is contingent upon continued employment or membership, which 28.31contains a provision for termination of coverage of the spouse upon dissolution of 28.32marriage shall contain a provision allowing a former spouse and dependent children of a 28.33subscriber, without providing evidence of insurability, to obtain from the corporation at 29.1the expiration of any continuation of coverage required under subdivision 2a or section 29.2, or upon termination of coverage by reason of an entry of a valid decree of 29.3dissolution which does not require the insured to provide continued coverage for the 29.4former spouse, an individual subscriber contract providing at least the minimum benefits 29.5of a qualified plan as prescribed by section and the option of a number three 29.6qualified plan, a number two qualified plan, a number one qualified plan as provided by 29.7section , subdivisions 1 to 3, provided application is made to the corporation within 29.830 days following notice of the expiration of the continued coverage and upon payment of 29.9the appropriate fee. A subscriber contract providing reduced benefits at a reduced fee may 29.10be accepted by the former spouse and dependent children in lieu of the optional coverage 29.11otherwise required by this subdivision. The new text begin An new text end individual subscriber contract new text begin issued as new text end 29.12 new text begin conversion coverage new text end shall be renewable at the option of the former spouse as long as the 29.13former spouse is not covered under another qualified plan as defined in section 62E.02, 29.14subdivision 4 . Any revisions in the table of rate for the individual subscriber contract shall 29.15apply to the former spouse's original age at entry and shall apply equally to all similar 29.16contracts issued new text begin as conversion coverage new text end by the corporation. 29.17 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 29.18    Sec. 34. Minnesota Statutes 2012, section 62D.07, subdivision 3, is amended to read: 29.19    Subd. 3. Required provisions. Contracts and evidences of coverage shall contain: 29.20(a) no provisions or statements which are unjust, unfair, inequitable, misleading, 29.21deceptive, or which are untrue, misleading, or deceptive as defined in section 62D.12, 29.22subdivision 1 ; 29.23(b) a clear, concise and complete statement of: 29.24(1) the health care services and the insurance or other benefits, if any, to which the 29.25enrollee is entitled under the health maintenance contract; 29.26(2) any exclusions or limitations on the services, kind of services, benefits, or kind of 29.27benefits, to be provided, including any deductible or co-payment feature and requirements 29.28for referrals, prior authorizations, and second opinions; 29.29(3) where and in what manner information is available as to how services, including 29.30emergency and out of area services, may be obtained; 29.31(4) the total amount of payment and co-payment, if any, for health care services 29.32and the indemnity or service benefits, if any, which the enrollee is obligated to pay 29.33with respect to individual contracts, or an indication whether the plan is contributory or 29.34noncontributory with respect to group certificates; and 30.1(5) a description of the health maintenance organization's method for resolving 30.2enrollee complaints and a statement identifying the commissioner as an external source 30.3with whom complaints may be registered; and 30.4(c) on the cover page of the evidence of coverage and contract, a clear and complete 30.5statement of enrollees' rights. The statement must be in bold print and captioned 30.6"Important Enrollee Information and Enrollee Bill of Rights" and must include but not be 30.7limited to the following provisions in the following language or in substantially similar 30.8language approved in advance by the commissioner, except that paragraph (8) does not 30.9apply to prepaid health plans providing coverage for programs administered by the 30.10commissioner of human services: 30.11ENROLLEE INFORMATION 30.12(1) COVERED SERVICES: Services provided by (name of health maintenance 30.13organization) will be covered only if services are provided by participating (name of 30.14health maintenance organization) providers or authorized by (name of health maintenance 30.15organization). Your contract fully defines what services are covered and describes 30.16procedures you must follow to obtain coverage. 30.17(2) PROVIDERS: Enrolling in (name of health maintenance organization) does not 30.18guarantee services by a particular provider on the list of providers. When a provider is 30.19no longer part of (name of health maintenance organization), you must choose among 30.20remaining (name of the health maintenance organization) providers. 30.21(3) REFERRALS: Certain services are covered only upon referral. See section 30.22(section number) of your contract for referral requirements. All referrals to non-(name of 30.23health maintenance organization) providers and certain types of health care providers must 30.24be authorized by (name of health maintenance organization). 30.25(4) EMERGENCY SERVICES: Emergency services from providers who are not 30.26affiliated with (name of health maintenance organization) will be covered only if proper 30.27procedures are followed. Your contract explains the procedures and benefits associated 30.28with emergency care from (name of health maintenance organization) and non-(name of 30.29health maintenance organization) providers. 30.30(5) EXCLUSIONS: Certain services or medical supplies are not covered. You 30.31should read the contract for a detailed explanation of all exclusions. 30.32(6) CONTINUATION: You may convert to an individual health maintenance 30.33organization contract or continue coverage under certain circumstances. These 30.34continuation and conversion rights are explained fully in your contract. 31.1(7) CANCELLATION: Your coverage may be canceled by you or (name of health 31.2maintenance organization) only under certain conditions. Your contract describes all 31.3reasons for cancellation of coverage. 31.4(8) NEWBORN COVERAGE: If your health plan provides for dependent coverage, 31.5a newborn infant is covered from birth, but only if services are provided by participating 31.6(name of health maintenance organization) providers or authorized by (name of health 31.7maintenance organization). Certain services are covered only upon referral. (Name 31.8of health maintenance organization) will not automatically know of the infant's birth 31.9or that you would like coverage under your plan. You should notify (name of health 31.10maintenance organization) of the infant's birth and that you would like coverage. If your 31.11contract requires an additional premium for each dependent, (name of health maintenance 31.12organization) is entitled to all premiums due from the time of the infant's birth until the 31.13time you notify (name of health maintenance organization) of the birth. (Name of health 31.14maintenance organization) may withhold payment of any health benefits for the newborn 31.15infant until any premiums you owe are paid. 31.16(9) PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT: Enrolling in (name 31.17of health maintenance organization) does not guarantee that any particular prescription 31.18drug will be available nor that any particular piece of medical equipment will be available, 31.19even if the drug or equipment is available at the start of the contract year. 31.20ENROLLEE BILL OF RIGHTS 31.21(1) Enrollees have the right to available and accessible services including emergency 31.22services, as defined in your contract, 24 hours a day and seven days a week; 31.23(2) Enrollees have the right to be informed of health problems, and to receive 31.24information regarding treatment alternatives and risks which is sufficient to assure 31.25informed choice; 31.26(3) Enrollees have the right to refuse treatment, and the right to privacy of medical 31.27and financial records maintained by the health maintenance organization and its health 31.28care providers, in accordance with existing law; 31.29(4) Enrollees have the right to file a complaint with the health maintenance 31.30organization and the commissioner of health and the right to initiate a legal proceeding 31.31when experiencing a problem with the health maintenance organization or its health 31.32care providers; 31.33(5) Enrollees have the right to a grace period of 31 days for the payment of each 31.34premium for an individual health maintenance contract falling due after the first premium 31.35during which period the contract shall continue in force; 32.1(6) Medicare enrollees have the right to voluntarily disenroll from the health 32.2maintenance organization and the right not to be requested or encouraged to disenroll 32.3except in circumstances specified in federal law; and 32.4(7) Medicare enrollees have the right to a clear description of nursing home and 32.5home care benefits covered by the health maintenance organization. 32.6 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 32.7    Sec. 35. Minnesota Statutes 2012, section 62D.095, is amended to read: 32.862D.095 ENROLLEE COST SHARING. 32.9    Subdivision 1. General application. A health maintenance contract may contain 32.10enrollee cost-sharing provisions as specified in this section. Co-payment and deductible 32.11provisions in a group contract must not discriminate on the basis of age, sex, race, 32.12disability, economic status, or length of enrollment in the health plan. During an 32.13open enrollment period in which all offered health plans fully participate without any 32.14underwriting restrictions, co-payment and deductible provisions must not discriminate 32.15on the basis of preexisting health status. 32.16    Subd. 2. Co-payments. (a) A health maintenance contract may impose a 32.17co-payment as authorized under Minnesota Rules, part 4685.0801, or under this section 32.18 new text begin and coinsurance consistent with the provisions of the Affordable Care Act as defined new text end 32.19 new text begin under section 62A.011, subdivision 1a new text end . 32.20(b) A health maintenance organization may impose a flat fee co-payment on 32.21outpatient office visits not to exceed 40 percent of the median provider's charges for 32.22similar services or goods received by the enrollees as calculated under Minnesota Rules, 32.23part 4685.0801. A health maintenance organization may impose a flat fee co-payment on 32.24outpatient prescription drugs not to exceed 50 percent of the median provider's charges 32.25for similar services or goods received by the enrollees as calculated under Minnesota 32.26Rules, part 4685.0801. 32.27(c) If a health maintenance contract is permitted to impose a co-payment for 32.28preexisting health status under sections to , these provisions may vary with 32.29respect to length of enrollment in the health plan. 32.30    Subd. 3. Deductibles. (a) A health maintenance contract issued by a health 32.31maintenance organization that is assessed less than three percent of the total annual amount 32.32assessed by the Minnesota comprehensive health association may impose deductibles not 32.33to exceed $3,000 per person, per year and $6,000 per family, per year. For purposes of 32.34the percentage calculation, a health maintenance organization's assessments include those 33.1of its affiliates new text begin may impose a deductible consistent with the provisions of the Affordable new text end 33.2 new text begin Care Act as defined under section 62A.011, subdivision 1a new text end . 33.3(b) All other health maintenance contracts may impose deductibles not to exceed 33.4$2,250 per person, per year and $4,500 per family, per year. 33.5    Subd. 4. Annual out-of-pocket maximums. (a) A health maintenance contract 33.6issued by a health maintenance organization that is assessed less than three percent of the 33.7total annual amount assessed by the Minnesota comprehensive health association must 33.8include a limitation not to exceed $4,500 per person and $7,500 per family on total annual 33.9out-of-pocket enrollee cost-sharing expenses. For purposes of the percentage calculation, 33.10a health maintenance organization's assessments include those of its affiliates new text begin may impose new text end 33.11 new text begin an annual out-of-pocket maximum consistent with the provisions of the Affordable Care new text end 33.12 new text begin Act as defined under section 62A.011, subdivision 1a new text end . 33.13(b) All other health maintenance contracts must include a limitation not to 33.14exceed $3,000 per person and $6,000 per family on total annual out-of-pocket enrollee 33.15cost-sharing expenses. 33.16    Subd. 5. Exceptions. No co-payments or deductibles may be imposed on preventive 33.17health care services as described in Minnesota Rules, part 4685.0801, subpart 8 new text begin consistent new text end 33.18 new text begin with the provisions of the Affordable Care Act as defined under section 62A.011, new text end 33.19 new text begin subdivision 1a new text end . 33.20    Subd. 6. Public programs. This section does not apply to the prepaid medical 33.21assistance program, the MinnesotaCare program, the prepaid general assistance program, 33.22the federal Medicare program, or the health plans provided through any of those programs. 33.23 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 33.24    Sec. 36. Minnesota Statutes 2012, section 62D.181, subdivision 7, is amended to read: 33.25    Subd. 7. Replacement coverage; limitations. The association is not obligated 33.26to offer replacement coverage under this chapter or conversion coverage under section 33.27 at the end of the periods specified in subdivision 6. Any continuation obligation 33.28arising under this chapter or chapter 62A will cease at the end of the periods specified in 33.29subdivision 6. 33.30 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 33.31    Sec. 37. Minnesota Statutes 2012, section 62E.02, is amended by adding a subdivision 33.32to read: 34.1     new text begin Subd. 2a. new text end new text begin Essential health benefits. new text end new text begin "Essential health benefits" has the meaning new text end 34.2 new text begin given under section 62Q.81, subdivision 4. new text end 34.3 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 34.4    Sec. 38. Minnesota Statutes 2012, section 62E.04, subdivision 4, is amended to read: 34.5    Subd. 4. Major medical coverage. Each insurer and fraternal shall affirmatively 34.6offer coverage of major medical expenses to every applicant who applies to the insurer 34.7or fraternal for a new unqualified policy, which has a lifetime benefit limit of less than 34.8$1,000,000, at the time of application and annually to every holder of such an unqualified 34.9policy of accident and health insurance renewed by the insurer or fraternal. The coverage 34.10shall provide that when a covered individual incurs out-of-pocket expenses of $5,000 34.11or more within a calendar year for services covered in section 62E.06, subdivision 1, 34.12benefits shall be payable, subject to any co-payment authorized by the commissioner, up 34.13to a maximum lifetime limit of not less than $1,000,000 new text begin and shall not contain a lifetime new text end 34.14 new text begin maximum on essential health benefits new text end . The offer of coverage of major medical expenses 34.15may consist of the offer of a rider on an existing unqualified policy or a new policy which 34.16is a qualified plan. 34.17 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 34.18    Sec. 39. Minnesota Statutes 2012, section 62E.04, is amended by adding a subdivision 34.19to read: 34.20     new text begin Subd. 11. new text end new text begin Essential health benefits package. new text end new text begin For individual or small group health new text end 34.21 new text begin plans that include the essential health benefits package and are offered, sold, issued, or new text end 34.22 new text begin renewed on or after January 1, 2014, the requirements of this section do not apply. new text end 34.23    Sec. 40. Minnesota Statutes 2012, section 62E.06, subdivision 1, is amended to read: 34.24    Subdivision 1. Number three plan. A plan of health coverage shall be certified as a 34.25number three qualified plan if it otherwise meets the requirements established by chapters 34.2662A, 62C, and 62Q, and the other laws of this state, whether or not the policy is issued in 34.27Minnesota, and meets or exceeds the following minimum standards: 34.28(a) The minimum benefits for a covered individual shall, subject to the other 34.29provisions of this subdivision, be equal to at least 80 percent of the cost of covered services 34.30in excess of an annual deductible which does not exceed $150 per person. The coverage 34.31shall include a limitation of $3,000 per person on total annual out-of-pocket expenses for 35.1services covered under this subdivision. The coverage shall new text begin not new text end be subject to a maximum 35.2lifetime benefit of not less than $1,000,000 new text begin lifetime maximum on essential health benefits new text end . 35.3The new text begin prohibition on lifetime maximums for essential health benefits and new text end $3,000 35.4limitation on total annual out-of-pocket expenses and the $1,000,000 maximum lifetime 35.5benefit shall not be subject to change or substitution by use of an actuarially equivalent 35.6benefit. 35.7(b) Covered expenses shall be the usual and customary charges for the following 35.8services and articles when prescribed by a physician: 35.9(1) hospital services; 35.10(2) professional services for the diagnosis or treatment of injuries, illnesses, or 35.11conditions, other than dental, which are rendered by a physician or at the physician's 35.12direction; 35.13(3) drugs requiring a physician's prescription; 35.14(4) services of a nursing home for not more than 120 days in a year if the services 35.15would qualify as reimbursable services under Medicare; 35.16(5) services of a home health agency if the services would qualify as reimbursable 35.17services under Medicare; 35.18(6) use of radium or other radioactive materials; 35.19(7) oxygen; 35.20(8) anesthetics; 35.21(9) prostheses other than dental but including scalp hair prostheses worn for hair 35.22loss suffered as a result of alopecia areata; 35.23(10) rental or purchase, as appropriate, of durable medical equipment other than 35.24eyeglasses and hearing aids, unless coverage is required under section 62Q.675; 35.25(11) diagnostic x-rays and laboratory tests; 35.26(12) oral surgery for partially or completely unerupted impacted teeth, a tooth root 35.27without the extraction of the entire tooth, or the gums and tissues of the mouth when not 35.28performed in connection with the extraction or repair of teeth; 35.29(13) services of a physical therapist; 35.30(14) transportation provided by licensed ambulance service to the nearest facility 35.31qualified to treat the condition; or a reasonable mileage rate for transportation to a kidney 35.32dialysis center for treatment; and 35.33(15) services of an occupational therapist. 35.34(c) Covered expenses for the services and articles specified in this subdivision do 35.35not include the following: 36.1(1) any charge for care for injury or disease either (i) arising out of an injury in the 36.2course of employment and subject to a workers' compensation or similar law, (ii) for 36.3which benefits are payable without regard to fault under coverage statutorily required 36.4to be contained in any motor vehicle, or other liability insurance policy or equivalent 36.5self-insurance, or (iii) for which benefits are payable under another policy of accident and 36.6health insurance, Medicare, or any other governmental program except as otherwise 36.7provided by section 62A.04, subdivision 3, clause (4); 36.8(2) any charge for treatment for cosmetic purposes other than for reconstructive 36.9surgery when such service is incidental to or follows surgery resulting from injury, 36.10sickness, or other diseases of the involved part or when such service is performed on a 36.11covered dependent child because of congenital disease or anomaly which has resulted in a 36.12functional defect as determined by the attending physician; 36.13(3) care which is primarily for custodial or domiciliary purposes which would not 36.14qualify as eligible services under Medicare; 36.15(4) any charge for confinement in a private room to the extent it is in excess of 36.16the institution's charge for its most common semiprivate room, unless a private room is 36.17prescribed as medically necessary by a physician, provided, however, that if the institution 36.18does not have semiprivate rooms, its most common semiprivate room charge shall be 36.19considered to be 90 percent of its lowest private room charge; 36.20(5) that part of any charge for services or articles rendered or prescribed by a 36.21physician, dentist, or other health care personnel which exceeds the prevailing charge in 36.22the locality where the service is provided; and 36.23(6) any charge for services or articles the provision of which is not within the scope 36.24of authorized practice of the institution or individual rendering the services or articles. 36.25(d) The minimum benefits for a qualified plan shall include, in addition to those 36.26benefits specified in clauses (a) and (e), benefits for well baby care, effective July 1, 36.271980, subject to applicable deductibles, coinsurance provisions, and maximum lifetime 36.28benefit limitations. 36.29(e) Effective July 1, 1979, the minimum benefits of a qualified plan shall include, in 36.30addition to those benefits specified in clause (a), a second opinion from a physician on 36.31all surgical procedures expected to cost a total of $500 or more in physician, laboratory, 36.32and hospital fees, provided that the coverage need not include the repetition of any 36.33diagnostic tests. 36.34(f) Effective August 1, 1985, the minimum benefits of a qualified plan must include, 36.35in addition to the benefits specified in clauses (a), (d), and (e), coverage for special dietary 36.36treatment for phenylketonuria when recommended by a physician. 37.1(g) Outpatient mental health coverage is subject to section 62A.152, subdivision 2. 37.2 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 37.3    Sec. 41. Minnesota Statutes 2012, section 62E.09, is amended to read: 37.462E.09 DUTIES OF COMMISSIONER. 37.5The commissioner may: 37.6(a) formulate general policies to advance the purposes of sections 62E.01 to 62E.19; 37.7(b) supervise the creation of the Minnesota Comprehensive Health Association 37.8within the limits described in section 62E.10; 37.9(c) approve the selection of the writing carrier by the association, approve the 37.10association's contract with the writing carrier, and approve the state plan coverage; 37.11(d) appoint advisory committees; 37.12(e) conduct periodic audits to assure the general accuracy of the financial data 37.13submitted by the writing carrier and the association; 37.14(f) contract with the federal government or any other unit of government to ensure 37.15coordination of the state plan with other governmental assistance programs; 37.16(g) undertake directly or through contracts with other persons studies or 37.17demonstration programs to develop awareness of the benefits of sections 62E.01 to 62E.16 37.18 new text begin 62E.15 new text end , so that the residents of this state may best avail themselves of the health care 37.19benefits provided by these sections; 37.20(h) contract with insurers and others for administrative services; and 37.21(i) adopt, amend, suspend and repeal rules as reasonably necessary to carry out and 37.22make effective the provisions and purposes of sections 62E.01 to 62E.19. 37.23 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 37.24    Sec. 42. Minnesota Statutes 2012, section 62E.10, subdivision 7, is amended to read: 37.25    Subd. 7. General powers. The association may: 37.26(a) Exercise the powers granted to insurers under the laws of this state; 37.27(b) Sue or be sued; 37.28(c) Enter into contracts with insurers, similar associations in other states or with 37.29other persons for the performance of administrative functions including the functions 37.30provided for in clauses (e) and (f); 37.31(d) Establish administrative and accounting procedures for the operation of the 37.32association; 38.1(e) Provide for the reinsuring of risks incurred as a result of issuing the coverages 38.2required by sections new text begin section new text end 62E.04 and by members of the association. Each 38.3member which elects to reinsure its required risks shall determine the categories of 38.4coverage it elects to reinsure in the association. The categories of coverage are: 38.5(1) individual qualified plans, excluding group conversions; 38.6(2) group conversions; 38.7(3) group qualified plans with fewer than 50 employees or members; and 38.8(4) major medical coverage. 38.9A separate election may be made for each category of coverage. If a member elects 38.10to reinsure the risks of a category of coverage, it must reinsure the risk of the coverage 38.11of every life covered under every policy issued in that category. A member electing to 38.12reinsure risks of a category of coverage shall enter into a contract with the association 38.13establishing a reinsurance plan for the risks. This contract may include provision for 38.14the pooling of members' risks reinsured through the association and it may provide for 38.15assessment of each member reinsuring risks for losses and operating and administrative 38.16expenses incurred, or estimated to be incurred in the operation of the reinsurance plan. This 38.17reinsurance plan shall be approved by the commissioner before it is effective. Members 38.18electing to administer the risks which are reinsured in the association shall comply with the 38.19benefit determination guidelines and accounting procedures established by the association. 38.20The fee charged by the association for the reinsurance of risks shall not be less than 110 38.21percent of the total anticipated expenses incurred by the association for the reinsurance; and 38.22(f) Provide for the administration by the association of policies which are reinsured 38.23pursuant to clause (e). Each member electing to reinsure one or more categories of 38.24coverage in the association may elect to have the association administer the categories of 38.25coverage on the member's behalf. If a member elects to have the association administer 38.26the categories of coverage, it must do so for every life covered under every policy issued 38.27in that category. The fee for the administration shall not be less than 110 percent of the 38.28total anticipated expenses incurred by the association for the administration. 38.29 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 38.30    Sec. 43. Minnesota Statutes 2012, section 62H.04, is amended to read: 38.3162H.04 COMPLIANCE WITH OTHER LAWS. 38.32(a) A joint self-insurance plan is subject to the requirements of chapters 62A, 62E, 38.3362L, and 62Q, and sections 72A.17 to 72A.32 unless otherwise specifically exempt. A 39.1joint self-insurance plan must pay assessments made by the Minnesota Comprehensive 39.2Health Association, as required under section 62E.11. 39.3(b) A joint self-insurance plan is exempt from providing the mandated health 39.4benefits described in chapters 62A, 62E, 62L, and 62Q if it otherwise provides the benefits 39.5required under the Employee Retirement Income Security Act of 1974, United States 39.6Code, title 29, sections 1001, et seq., for all employers and not just for the employers with 39.750 or more employees who are covered by that federal law. 39.8(c) A joint self-insurance plan is exempt from section 62L.03, subdivision 1, if the 39.9plan offers an annual open enrollment period of no less than 15 days during which all 39.10employers that qualify for membership may enter the plan without preexisting condition 39.11limitations or exclusions except those permitted under chapter 62L. 39.12(d) A joint self-insurance plan is exempt from sections 62A.146, 62A.16, 62A.17, 39.1362A.20 , 62A.21, new text begin and new text end 62A.65, subdivision 5, paragraph (b), and if the joint 39.14self-insurance plan complies with the continuation requirements under the Employee 39.15Retirement Income Security Act of 1974, United States Code, title 29, sections 1001, et 39.16seq., for all employers and not just for the employers with 20 or more employees who 39.17are covered by that federal law. 39.18(e) A joint self-insurance plan must provide to all employers the maternity coverage 39.19required by federal law for employers with 15 or more employees. 39.20 new text begin (f) A joint self-insurance plan must comply with all the provisions and requirements new text end 39.21 new text begin of the Affordable Care Act as defined under section 62A.011, subdivision 1a, to the extent new text end 39.22 new text begin that they apply to such plans. new text end 39.23 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment, new text end 39.24 new text begin except that the amendment to paragraph (d) is effective January 1, 2014. new text end 39.25    Sec. 44. Minnesota Statutes 2012, section 62L.02, subdivision 11, is amended to read: 39.26    Subd. 11. Dependent. "Dependent" means an eligible employee's spouse, 39.27unmarried child who is under the age of 25 years new text begin dependent child to the limiting age as new text end 39.28 new text begin defined in section 62Q.01, subdivision 9 new text end , dependent child of any age who is disabled and 39.29who meets the eligibility criteria in section 62A.14, subdivision 2, or any other person 39.30whom state or federal law requires to be treated as a dependent for purposes of health 39.31plans. For the purpose of this definition, a new text begin dependent new text end child new text begin to the limiting age as defined in new text end 39.32 new text begin section 62Q.01, subdivision 9, new text end includes a child for whom the employee or the employee's 39.33spouse has been appointed legal guardian and an adoptive child as provided in section 39.3462A.27 . new text begin A child also means a grandchild as provided in section 62A.042 with continued new text end 39.35 new text begin eligibility of grandchildren as provided in section 62A.302, subdivision 4. new text end 40.1 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 40.2    Sec. 45. Minnesota Statutes 2012, section 62L.02, subdivision 14a, is amended to read: 40.3    Subd. 14a. Guaranteed issue. "Guaranteed issue" means that a health carrier shall 40.4not decline an application by a small employer for any health benefit plan offered by 40.5that health carrier and shall not decline to cover under a health benefit plan any eligible 40.6employee or eligible dependent, including persons who become eligible employees or 40.7eligible dependents after initial issuance of the health benefit plan, subject to the health 40.8carrier's right to impose preexisting condition limitations permitted under this chapter. 40.9 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 40.10    Sec. 46. Minnesota Statutes 2012, section 62L.02, is amended by adding a subdivision 40.11to read: 40.12     new text begin Subd. 17a. new text end new text begin Individual health plan. new text end new text begin "Individual health plan" has the meaning new text end 40.13 new text begin given in section 62A.011, subdivision 4. new text end 40.14 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 40.15    Sec. 47. Minnesota Statutes 2012, section 62L.02, subdivision 26, is amended to read: 40.16    Subd. 26. Small employer. (a) "Small employer" means, with respect to a calendar 40.17year and a plan year, a person, firm, corporation, partnership, association, or other entity 40.18actively engaged in business in Minnesota, including a political subdivision of the state, that 40.19employed an average of no fewer than two nor new text begin at least one, not including a sole proprietor, new text end 40.20 new text begin but not new text end more than 50 current employees on business days during the preceding calendar 40.21year and that employs at least two new text begin one new text end current employees new text begin employee, not including a sole new text end 40.22 new text begin proprietor, new text end on the first day of the plan year. If an employer has only one eligible employee 40.23who has not waived coverage, the sale of a health plan to or for that eligible employee 40.24is not a sale to a small employer and is not subject to this chapter and may be treated as 40.25the sale of an individual health plan. A small employer plan may be offered through a 40.26domiciled association to self-employed individuals and small employers who are members 40.27of the association, even if the self-employed individual or small employer has fewer than 40.28two current employees. Entities that are treated as a single employer under subsection (b), 40.29(c), (m), or (o) of section 414 of the federal Internal Revenue Code are considered a single 40.30employer for purposes of determining the number of current employees. Small employer 40.31status must be determined on an annual basis as of the renewal date of the health benefit 40.32plan. The provisions of this chapter continue to apply to an employer who no longer meets 41.1the requirements of this definition until the annual renewal date of the employer's health 41.2benefit plan. If an employer was not in existence throughout the preceding calendar year, 41.3the determination of whether the employer is a small employer is based upon the average 41.4number of current employees that it is reasonably expected that the employer will employ 41.5on business days in the current calendar year. For purposes of this definition, the term 41.6employer includes any predecessor of the employer. An employer that has more than 50 41.7current employees but has 50 or fewer employees, as "employee" is defined under United 41.8States Code, title 29, section 1002(6), is a small employer under this subdivision. 41.9(b) Where an association, as defined in section 62L.045, comprised of employers 41.10contracts with a health carrier to provide coverage to its members who are small employers, 41.11the association and health benefit plans it provides to small employers, are subject to 41.12section 62L.045, with respect to small employers in the association, even though the 41.13association also provides coverage to its members that do not qualify as small employers. 41.14(c) If an employer has employees covered under a trust specified in a collective 41.15bargaining agreement under the federal Labor-Management Relations Act of 1947, 41.16United States Code, title 29, section 141, et seq., as amended, or employees whose health 41.17coverage is determined by a collective bargaining agreement and, as a result of the 41.18collective bargaining agreement, is purchased separately from the health plan provided 41.19to other employees, those employees are excluded in determining whether the employer 41.20qualifies as a small employer. Those employees are considered to be a separate small 41.21employer if they constitute a group that would qualify as a small employer in the absence 41.22of the employees who are not subject to the collective bargaining agreement. 41.23 new text begin (d) Small group health plans offered through the Minnesota Insurance Marketplace new text end 41.24 new text begin under chapter 62V to employees of a small employer are not considered individual health new text end 41.25 new text begin plans, regardless of whether the health plan is purchased using a defined contribution new text end 41.26 new text begin from the small employer. new text end 41.27 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 41.28    Sec. 48. Minnesota Statutes 2012, section 62L.03, subdivision 1, is amended to read: 41.29    Subdivision 1. Guaranteed issue and reissue. (a) Every health carrier shall, as a 41.30condition of authority to transact business in this state in the small employer market, 41.31affirmatively market, offer, sell, issue, and renew any of its health benefit plans, on a 41.32guaranteed issue basis, to any small employer, including a small employer covered by 41.33paragraph (b), that meets the participation and contribution requirements of subdivision 3, 41.34as provided in this chapter. 42.1(b) A small employer that has its new text begin no longer meets the definition of small employer new text end 42.2 new text begin because of a reduction in new text end workforce reduced to one employee may continue coverage as a 42.3small employer for 12 months from the date the group is reduced to one employee. 42.4(c) Notwithstanding paragraph (a), a health carrier may, at the time of coverage 42.5renewal, modify the health coverage for a product offered in the small employer market if 42.6the modification is consistent with state law, approved by the commissioner, and effective 42.7on a uniform basis for all small employers purchasing that product other than through a 42.8qualified association in compliance with section 62L.045, subdivision 2. 42.9Paragraph (a) does not apply to a health benefit plan designed for a small employer 42.10to comply with a collective bargaining agreement, provided that the health benefit plan 42.11otherwise complies with this chapter and is not offered to other small employers, except 42.12for other small employers that need it for the same reason. This paragraph applies only 42.13with respect to collective bargaining agreements entered into prior to August 21, 1996, 42.14and only with respect to plan years beginning before the later of July 1, 1997, or the date 42.15upon which the last of the collective bargaining agreements relating to the plan terminates 42.16determined without regard to any extension agreed to after August 21, 1996. 42.17(d) Every health carrier participating in the small employer market shall make 42.18available both of the plans described in section to small employers and shall fully 42.19comply with the underwriting and the rate restrictions specified in this chapter for all 42.20health benefit plans issued to small employers. 42.21(e) new text begin (d) new text end A health carrier may cease to transact business in the small employer market 42.22as provided under section 62L.09. 42.23 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 42.24    Sec. 49. Minnesota Statutes 2012, section 62L.03, subdivision 3, is amended to read: 42.25    Subd. 3. Minimum participation and contribution. (a) A small employer that has 42.26at least 75 percent of its eligible employees who have not waived coverage participating in 42.27a health benefit plan and that contributes at least 50 percent toward the cost of coverage of 42.28each eligible employee must be guaranteed coverage on a guaranteed issue basis from 42.29any health carrier participating in the small employer market. The participation level 42.30of eligible employees must be determined at the initial offering of coverage and at the 42.31renewal date of coverage. A health carrier must not increase the participation requirements 42.32applicable to a small employer at any time after the small employer has been accepted for 42.33coverage. For the purposes of this subdivision, waiver of coverage includes only waivers 42.34due to: (1) coverage under another group health plan; (2) coverage under Medicare 43.1Parts A and B; or (3) coverage under medical assistance under chapter 256B or general 43.2assistance medical care under chapter 256D. 43.3    (b) If a small employer does not satisfy the contribution or participation requirements 43.4under this subdivision, a health carrier may voluntarily issue or renew individual health 43.5plans, or a health benefit plan which must fully comply with this chapter. A health carrier 43.6that provides a health benefit plan to a small employer that does not meet the contribution 43.7or participation requirements of this subdivision must maintain this information in its files 43.8for audit by the commissioner. A health carrier may not offer an individual health plan, 43.9purchased through an arrangement between the employer and the health carrier, to any 43.10employee unless the health carrier also offers the individual health plan, on a guaranteed 43.11issue basis, to all other employees of the same employer. An arrangement permitted 43.12under section 62L.12, subdivision 2, paragraph (k) new text begin (l) new text end , is not an arrangement between the 43.13employer and the health carrier for purposes of this paragraph. 43.14    (c) Nothing in this section obligates a health carrier to issue coverage to a small 43.15employer that currently offers coverage through a health benefit plan from another health 43.16carrier, unless the new coverage will replace the existing coverage and not serve as one 43.17of two or more health benefit plans offered by the employer. This paragraph does not 43.18apply if the small employer will meet the required participation level with respect to 43.19the new coverage. 43.20 new text begin (d) If a small employer cannot meet either the participation or contribution new text end 43.21 new text begin requirement, the small employer may purchase coverage only during an open enrollment new text end 43.22 new text begin period each year between November 15 and December 15. new text end 43.23 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 43.24    Sec. 50. Minnesota Statutes 2012, section 62L.03, subdivision 4, is amended to read: 43.25    Subd. 4. Underwriting restrictions. (a) Health carriers may apply underwriting 43.26restrictions to coverage for health benefit plans for small employers, including any 43.27preexisting condition limitations, only as expressly permitted under this chapter. For 43.28purposes of this section, "underwriting restrictions" means any refusal of the health carrier 43.29to issue or renew coverage, any premium rate higher than the lowest rate charged by the 43.30health carrier for the same coverage, any preexisting condition limitation, preexisting 43.31condition exclusion, or any exclusionary rider. 43.32(b) Health carriers may collect information relating to the case characteristics and 43.33demographic composition of small employers, as well as health status and health history 43.34information about employees, and dependents of employees, of small employers. 44.1(c) Except as otherwise authorized for late entrants, preexisting conditions may be 44.2excluded by a health carrier for a period not to exceed 12 months from the enrollment 44.3date of an eligible employee or dependent, but exclusionary riders must not be used. Late 44.4entrants may be subject to a preexisting condition limitation not to exceed 18 months from 44.5the enrollment date of the late entrant, but must not be subject to any exclusionary rider or 44.6preexisting condition exclusion. When calculating any length of preexisting condition 44.7limitation, a health carrier shall credit the time period an eligible employee or dependent 44.8was previously covered by qualifying coverage, provided that the individual maintains 44.9continuous coverage. The credit must be given for all qualifying coverage with respect 44.10to all preexisting conditions, regardless of whether the conditions were preexisting with 44.11respect to any previous qualifying coverage. Section , relating to replacement of 44.12group coverage, and the rules adopted under that section apply to this chapter, and this 44.13chapter's requirements are in addition to the requirements of that section and the rules 44.14adopted under it. A health carrier shall, at the time of first issuance or renewal of a health 44.15benefit plan on or after July 1, 1993, credit against any preexisting condition limitation 44.16or exclusion permitted under this section, the time period prior to July 1, 1993, during 44.17which an eligible employee or dependent was covered by qualifying coverage, if the 44.18person has maintained continuous coverage. 44.19(d) Health carriers shall not use pregnancy as a preexisting condition under this 44.20chapter. 44.21 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 44.22    Sec. 51. Minnesota Statutes 2012, section 62L.03, subdivision 6, is amended to read: 44.23    Subd. 6. MCHA enrollees. Health carriers shall offer coverage to any eligible 44.24employee or dependent enrolled in MCHA at the time of the health carrier's issuance or 44.25renewal of a health benefit plan to a small employer. The health benefit plan must require 44.26that the employer permit MCHA enrollees to enroll in the small employer's health benefit 44.27plan as of the first date of renewal of a health benefit plan occurring on or after July 44.281, 1993, and as of each date of renewal after that, or, in the case of a new group, as of 44.29the initial effective date of the health benefit plan and as of each date of renewal after 44.30that. Unless otherwise permitted by this chapter, Health carriers must not impose any 44.31underwriting restrictions, including any preexisting condition limitations or exclusions, on 44.32any eligible employee or dependent previously enrolled in MCHA and transferred to a 44.33health benefit plan so long as continuous coverage is maintained, provided that the health 44.34carrier may impose any unexpired portion of a preexisting condition limitation under the 45.1person's MCHA coverage. An MCHA enrollee is not a late entrant, so long as the enrollee 45.2has maintained continuous coverage. 45.3 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 45.4    Sec. 52. Minnesota Statutes 2012, section 62L.045, subdivision 2, is amended to read: 45.5    Subd. 2. Qualified associations. (a) A qualified association, as defined in this 45.6section, and health coverage offered by it, to it, or through it, to a small employer in 45.7this state must comply with the requirements of this chapter regarding guaranteed issue, 45.8guaranteed renewal, preexisting condition limitations, credit against preexisting condition 45.9limitations for continuous coverage, treatment of MCHA enrollees, and the definition of 45.10dependent, and with section 62A.65, subdivision 5, paragraph (b). They must also comply 45.11with all other requirements of this chapter not specifically exempted in paragraph (b) or (c). 45.12(b) A qualified association and a health carrier offering, selling, issuing, or renewing 45.13health coverage to, or to cover, a small employer in this state through the qualified 45.14association, may, but are not, in connection with that health coverage, required to: 45.15(1) offer the two small employer plans described in section 62L.05; and 45.16(2) offer to small employers that are not members of the association, health coverage 45.17offered to, by, or through the qualified association. 45.18(c) A qualified association, and a health carrier offering, selling, issuing, and 45.19renewing health coverage to, or to cover, a small employer in this state must comply 45.20with section , except that: 45.21(1) a separate index rate may be applied by a health carrier to each qualified 45.22association, provided that: 45.23(i) the premium rate applied to participating small employer members of the 45.24qualified association is no more than 25 percent above and no more than 25 percent below 45.25the index rate applied to the qualified association, irrespective of when members applied 45.26for health coverage; and 45.27(ii) the index rate applied by a health carrier to a qualified association is no more 45.28than 20 percent above and no more than 20 percent below the index rate applied by the 45.29health carrier to any other qualified association or to any small employer. In comparing 45.30index rates for purposes of this clause, the 20 percent shall be calculated as a percent of 45.31the larger index rate; and 45.32(2) a qualified association described in subdivision 1, paragraph (a), clauses (2) 45.33to (4), providing health coverage through a health carrier, or on a self-insured basis in 45.34compliance with section and the rules adopted under that section, may cover 45.35small employers and other employers within the same pool and may charge premiums 46.1to small employer members on the same basis as it charges premiums to members that 46.2are not small employers, if the premium rates charged to small employers do not have 46.3greater variation than permitted under section . A qualified association operating 46.4under this clause shall annually prove to the commissioner of commerce that it complies 46.5with this clause through a sampling procedure acceptable to the commissioner. If the 46.6qualified association fails to prove compliance to the satisfaction of the commissioner, 46.7the association shall agree to a written plan of correction acceptable to the commissioner. 46.8The qualified association is considered to be in compliance under this clause if there is 46.9a premium rate that would, if used as an index rate, result in all premium rates in the 46.10sample being in compliance with section . This clause does not exempt a qualified 46.11association or a health carrier providing coverage through the qualified association from 46.12the loss ratio requirement of section 62L.08, subdivision 11. 46.13 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 46.14    Sec. 53. Minnesota Statutes 2012, section 62L.045, subdivision 4, is amended to read: 46.15    Subd. 4. Principles; association coverage. (a) This subdivision applies to 46.16associations as defined in this section, whether qualified associations or not, and is 46.17intended to clarify subdivisions 1 to 3. 46.18(b) This section applies only to associations that provide health coverage to small 46.19employers. 46.20(c) A health carrier is not required under this chapter to comply with guaranteed 46.21issue and guaranteed renewal with respect to its relationship with the association itself. 46.22 An arrangement between the health carrier and the association, once entered into, must 46.23comply with guaranteed issue and guaranteed renewal with respect to members of the 46.24association that are small employers and persons covered through them. 46.25(d) When an arrangement between a health carrier and an association has validly 46.26terminated, the health carrier has no continuing obligation to small employers and persons 46.27covered through them, except as otherwise provided in: 46.28(1) section 62A.65, subdivision 5, paragraph (b); 46.29(2) any other continuation or conversion rights applicable under state or federal 46.30law; and 46.31(3) section 60A.082, relating to group replacement coverage, and rules adopted 46.32under that section. 46.33(e) When an association's arrangement with a health carrier has terminated and the 46.34association has entered into a new arrangement with that health carrier or a different 46.35health carrier, the new arrangement is subject to section 60A.082 and rules adopted under 47.1it, with respect to members of the association that are small employers and persons 47.2covered through them. 47.3(f) An association that offers its members more than one plan of health coverage 47.4may have uniform rules restricting movement between the plans of health coverage, if the 47.5rules do not discriminate against small employers. 47.6(g) This chapter does not require or prohibit separation of an association's members 47.7into one group consisting only of small employers and another group or other groups 47.8consisting of all other members. The association must comply with this section with 47.9respect to the small employer group. 47.10(h) For purposes of this section, "member" of an association includes an employer 47.11participant in the association. 47.12(i) For purposes of this section, health coverage issued to, or to cover, a small 47.13employer includes a certificate of coverage issued directly to the employer's employees 47.14and dependents, rather than to the small employer. 47.15 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 47.16    Sec. 54. Minnesota Statutes 2012, section 62L.05, subdivision 10, is amended to read: 47.17    Subd. 10. Medical expense reimbursement. Health carriers may reimburse 47.18or pay for medical services, supplies, or articles provided under a small employer plan 47.19in accordance with the health carrier's provider contract requirements including, but 47.20not limited to, salaried arrangements, capitation, the payment of usual and customary 47.21charges, fee schedules, discounts from fee-for-service, per diems, diagnosis-related 47.22groups (DRGs), and other payment arrangements. Nothing in this chapter requires a 47.23health carrier to develop, implement, or change its provider contract requirements for 47.24a small employer plan. Coinsurance, deductibles, new text begin and new text end out-of-pocket maximums, and 47.25maximum lifetime benefits must be calculated and determined in accordance with each 47.26health carrier's standard business practices. 47.27 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 47.28    Sec. 55. Minnesota Statutes 2012, section 62L.06, is amended to read: 47.2962L.06 DISCLOSURE OF UNDERWRITING RATING PRACTICES. 47.30When offering or renewing a health benefit plan, health carriers shall disclose in all 47.31solicitation and sales materials: 47.32(1) the case characteristics and other rating factors used to determine initial and 47.33renewal rates; 48.1(2) the extent to which premium rates for a small employer are established or 48.2adjusted based upon actual or expected variation in claim experience; 48.3(3) provisions concerning the health carrier's right to change premium rates and the 48.4factors other than claim experience that affect changes in premium rates; 48.5(4) new text begin (2) new text end provisions relating to renewability of coverage; 48.6(5) the use and effect of any preexisting condition provisions, if permitted; 48.7(6) new text begin (3) new text end the application of any provider network limitations and their effect on 48.8eligibility for benefits; and 48.9(7) new text begin (4) new text end the ability of small employers to insure eligible employees and dependents 48.10currently receiving coverage from the Comprehensive Health Association through health 48.11benefit plans. 48.12 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 48.13    Sec. 56. Minnesota Statutes 2012, section 62L.08, is amended to read: 48.1462L.08 RESTRICTIONS RELATING TO PREMIUM RATES. 48.15    Subdivision 1. Rate restrictions. Premium rates for all health benefit plans sold or 48.16issued to small employers are subject to the restrictions specified in this section. 48.17    Subd. 2. General premium variations. Beginning July 1, 1993, each health carrier 48.18must offer premium rates to small employers that are no more than 25 percent above 48.19and no more than 25 percent below the index rate charged to small employers for the 48.20same or similar coverage, adjusted pro rata for rating periods of less than one year. The 48.21premium variations permitted by this subdivision must be based only on health status, 48.22claims experience, industry of the employer, and duration of coverage from the date of 48.23issue. For purposes of this subdivision, health status includes refraining from tobacco use 48.24or other actuarially valid lifestyle factors associated with good health, provided that the 48.25lifestyle factor and its effect upon premium rates have been determined to be actuarially 48.26valid and approved by the commissioner. Variations permitted under this subdivision must 48.27not be based upon age or applied differently at different ages. This subdivision does not 48.28prohibit use of a constant percentage adjustment for factors permitted to be used under 48.29this subdivision. 48.30    Subd. 2a. Renewal premium increases limited. (a) Beginning January 1, 2003, 48.31the percentage increase in the premium rate charged to a small employer for a new rating 48.32period must not exceed the sum of the following: 48.33(1) the percentage change in the index rate measured from the first day of the prior 48.34rating period to the first day of the new rating period; 49.1(2) an adjustment, not to exceed 15 percent annually and adjusted pro rata for rating 49.2periods of less than one year, due to the claims experience, health status, or duration of 49.3coverage of the employees or dependents of the employer; and 49.4(3) any adjustment due to change in coverage or in the case characteristics of the 49.5employer. 49.6(b) This subdivision does not apply if the employer, employee, or any applicant 49.7provides the health carrier with false, incomplete, or misleading information. 49.8    Subd. 3. Age-based premium variations. Beginning July 1, 1993, Each health 49.9carrier may offer premium rates to small employers that vary based upon the ages of 49.10the eligible employees and dependents of the small employer only as provided in this 49.11subdivision. In addition to the variation permitted by subdivision 2, each health carrier 49.12may use an additional premium variation based upon age of up to plus or minus 50 percent 49.13of the index rate. new text begin Premium rates may vary based upon the ages of the eligible employees new text end 49.14 new text begin and dependents of the small employer in accordance with the provisions of the Affordable new text end 49.15 new text begin Care Act as defined in section 62A.011, subdivision 1a. new text end 49.16    Subd. 4. Geographic premium variations. A health carrier may request approval 49.17by the commissioner to establish separate geographic regions determined by the health 49.18carrier and to establish separate index rates for each such region new text begin Premium rates may vary new text end 49.19 new text begin based on geographic rating areas set by the commissioner new text end . The commissioner shall grant 49.20approval if the following conditions are met: 49.21(1) the geographic regions must be applied uniformly by the health carrier; 49.22(2) each geographic region must be composed of no fewer than seven counties that 49.23create a contiguous region; and 49.24(3) the health carrier provides actuarial justification acceptable to the commissioner 49.25for the proposed geographic variations in index rates, establishing that the variations are 49.26based upon differences in the cost to the health carrier of providing coverage. 49.27    Subd. 5. Gender-based rates prohibited. Beginning July 1, 1993, No health carrier 49.28may determine premium rates through a method that is in any way based upon the gender 49.29of eligible employees or dependents. Rates must not in any way reflect marital status or 49.30generalized differences in expected costs between employees and spouses. 49.31    Subd. 6. Rate cells permitted new text begin Tobacco rating new text end . Health carriers may use rate cells 49.32and must file with the commissioner the rate cells they use. Rate cells must be based on 49.33the number of adults and children covered under the policy and may reflect the availability 49.34of Medicare coverage. The rates for different rate cells must not in any way reflect marital 49.35status or differences in expected costs between employees and spouses new text begin Premium rates new text end 50.1 new text begin may vary based upon tobacco use in accordance with the provisions of the Affordable new text end 50.2 new text begin Care Act as defined in section 62A.011, subdivision 1a new text end . 50.3    Subd. 7. Index and Premium rate development. (a) In developing its index rates 50.4and premiums, a health carrier may take into account only the following factors: 50.5(1) actuarially valid differences in benefit designs of health benefit plans; new text begin and new text end 50.6(2) actuarially valid differences in the rating factors permitted in subdivisions 2 and 3; 50.7(3) new text begin (2) new text end actuarially valid geographic variations if approved by the commissioner as 50.8provided in subdivision 4. 50.9(b) All premium variations permitted under this section must be based upon 50.10actuarially valid differences in expected cost to the health carrier of providing coverage. 50.11The variation must be justified in initial rate filings and upon request of the commissioner in 50.12rate revision filings. All premium variations are subject to approval by the commissioner. 50.13    Subd. 8. Filing requirement. A health carrier that offers, sells, issues, or renews a 50.14health benefit plan for small employers shall file with the commissioner the index rates and 50.15must demonstrate that all rates shall be within the rating restrictions defined in this chapter. 50.16Such demonstration must include the allowable range of rates from the index rates and a 50.17description of how the health carrier intends to use demographic factors including case 50.18characteristics in calculating the premium rates. The rates shall not be approved, unless the 50.19commissioner has determined that the rates are reasonable. In determining reasonableness, 50.20the commissioner shall consider the growth rates applied under section 62J.04, subdivision 50.211 , paragraph (b), to the calendar year or years that the proposed premium rate would be in 50.22effect, new text begin and new text end actuarially valid changes in risk associated with the enrollee population, and 50.23actuarially valid changes as a result of statutory changes in Laws 1992, chapter 549. 50.24    Subd. 9. Effect of assessments. Premium rates must comply with the rating 50.25requirements of this section, notwithstanding the imposition of any assessments or 50.26premiums paid by health carriers as provided under sections 62L.13 to 62L.22. 50.27    Subd. 10. Rating report. Beginning January 1, 1995, and annually thereafter, the 50.28commissioners of health and commerce shall provide a joint report to the legislature 50.29on the effect of the rating restrictions required by this section and the appropriateness 50.30of proceeding with additional rate reform. Each report must include an analysis of the 50.31availability of health care coverage due to the rating reform, the equitable and appropriate 50.32distribution of risk and associated costs, the effect on the self-insurance market, and any 50.33resulting or anticipated change in health plan design and market share and availability of 50.34health carriers. 50.35    Subd. 11. Loss ratio standards. Notwithstanding section 62A.02, subdivision 3, 50.36relating to loss ratios, each policy or contract form used with respect to a health benefit 51.1plan offered, or issued in the small employer market, is subject, beginning July 1, 1993, 51.2to section 62A.021. The commissioner of health has, with respect to carriers under that 51.3commissioner's jurisdiction, all of the powers of the commissioner of commerce under 51.4that section. 51.5 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 51.6    Sec. 57. Minnesota Statutes 2012, section 62L.12, subdivision 2, is amended to read: 51.7    Subd. 2. Exceptions. (a) A health carrier may sell, issue, or renew individual 51.8conversion policies to eligible employees otherwise eligible for conversion coverage under 51.9section 62D.104 as a result of leaving a health maintenance organization's service area. 51.10(b) A health carrier may sell, issue, or renew individual conversion policies to 51.11eligible employees otherwise eligible for conversion coverage as a result of the expiration 51.12of any continuation of group coverage required under sections 62A.146, 62A.17, 62A.21, 51.1362C.142 , 62D.101, and 62D.105. 51.14(c) A health carrier may sell, issue, or renew conversion policies under section 51.15 to eligible employees. 51.16(d) A health carrier may sell, issue, or renew individual continuation policies to 51.17eligible employees as required. 51.18(e) A health carrier may sell, issue, or renew individual health plans if the coverage 51.19is appropriate due to an unexpired preexisting condition limitation or exclusion applicable 51.20to the person under the employer's group health plan or due to the person's need for health 51.21care services not covered under the employer's group health plan. 51.22(f) A health carrier may sell, issue, or renew an individual health plan, if the 51.23individual has elected to buy the individual health plan not as part of a general plan to 51.24substitute individual health plans for a group health plan nor as a result of any violation of 51.25subdivision 3 or 4. 51.26(g) new text begin A health carrier may sell, issue, or renew an individual health plan if coverage new text end 51.27 new text begin provided by the employer is determined to be unaffordable under the provisions of the new text end 51.28 new text begin Affordable Care Act as defined in section 62A.011, subdivision 1a. new text end 51.29 new text begin (h) new text end Nothing in this subdivision relieves a health carrier of any obligation to provide 51.30continuation or conversion coverage otherwise required under federal or state law. 51.31(h) new text begin (i) new text end Nothing in this chapter restricts the offer, sale, issuance, or renewal of 51.32coverage issued as a supplement to Medicare under sections 62A.3099 to 62A.44, or 51.33policies or contracts that supplement Medicare issued by health maintenance organizations, 51.34or those contracts governed by sections 1833, 1851 to 1859, 1860D, or 1876 of the federal 51.35Social Security Act, United States Code, title 42, section 1395 et seq., as amended. 52.1(i) new text begin (j) new text end Nothing in this chapter restricts the offer, sale, issuance, or renewal of 52.2individual health plans necessary to comply with a court order. 52.3(j) new text begin (k) new text end A health carrier may offer, issue, sell, or renew an individual health plan to 52.4persons eligible for an employer group health plan, if the individual health plan is a high 52.5deductible health plan for use in connection with an existing health savings account, in 52.6compliance with the Internal Revenue Code, section 223. In that situation, the same or 52.7a different health carrier may offer, issue, sell, or renew a group health plan to cover 52.8the other eligible employees in the group. 52.9(k) new text begin (l) new text end A health carrier may offer, sell, issue, or renew an individual health plan to 52.10one or more employees of a small employer if the individual health plan is marketed 52.11directly to all employees of the small employer and the small employer does not contribute 52.12directly or indirectly to the premiums or facilitate the administration of the individual 52.13health plan. The requirement to market an individual health plan to all employees does not 52.14require the health carrier to offer or issue an individual health plan to any employee. For 52.15purposes of this paragraph, an employer is not contributing to the premiums or facilitating 52.16the administration of the individual health plan if the employer does not contribute to the 52.17premium and merely collects the premiums from an employee's wages or salary through 52.18payroll deductions and submits payment for the premiums of one or more employees in a 52.19lump sum to the health carrier. Except for coverage under section 62A.65, subdivision 5, 52.20paragraph (b), or , at the request of an employee, the health carrier may bill the 52.21employer for the premiums payable by the employee, provided that the employer is not 52.22liable for payment except from payroll deductions for that purpose. If an employer is 52.23submitting payments under this paragraph, the health carrier shall provide a cancellation 52.24notice directly to the primary insured at least ten days prior to termination of coverage for 52.25nonpayment of premium. Individual coverage under this paragraph may be offered only 52.26if the small employer has not provided coverage under section 62L.03 to the employees 52.27within the past 12 months. 52.28The employer must provide a written and signed statement to the health carrier that 52.29the employer is not contributing directly or indirectly to the employee's premiums. The 52.30health carrier may rely on the employer's statement and is not required to guarantee-issue 52.31individual health plans to the employer's other current or future employees. 52.32 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 52.33    Sec. 58. Minnesota Statutes 2012, section 62M.05, subdivision 3a, is amended to read: 52.34    Subd. 3a. Standard review determination. (a) Notwithstanding subdivision 3b, an 52.35initial determination on all requests for utilization review must be communicated to the 53.1provider and enrollee in accordance with this subdivision within ten business days of the 53.2request, provided that all information reasonably necessary to make a determination on the 53.3request has been made available to the utilization review organization. 53.4(b) When an initial determination is made to certify, notification must be provided 53.5promptly by telephone to the provider. The utilization review organization shall send 53.6written notification to the provider or shall maintain an audit trail of the determination 53.7and telephone notification. For purposes of this subdivision, "audit trail" includes 53.8documentation of the telephone notification, including the date; the name of the person 53.9spoken to; the enrollee; the service, procedure, or admission certified; and the date of 53.10the service, procedure, or admission. If the utilization review organization indicates 53.11certification by use of a number, the number must be called the "certification number." 53.12For purposes of this subdivision, notification may also be made by facsimile to a verified 53.13number or by electronic mail to a secure electronic mailbox. These electronic forms of 53.14notification satisfy the "audit trail" requirement of this paragraph. 53.15(c) When an initial determination is made not to certify, notification must be 53.16provided by telephone, by facsimile to a verified number, or by electronic mail to a secure 53.17electronic mailbox within one working day after making the determination to the attending 53.18health care professional and hospital as applicable. Written notification must also be sent 53.19to the hospital as applicable and attending health care professional if notification occurred 53.20by telephone. For purposes of this subdivision, notification may be made by facsimile to a 53.21verified number or by electronic mail to a secure electronic mailbox. Written notification 53.22must be sent to the enrollee and may be sent by United States mail, facsimile to a verified 53.23number, or by electronic mail to a secure mailbox. The written notification must include 53.24the principal reason or reasons for the determination and the process for initiating an appeal 53.25of the determination. Upon request, the utilization review organization shall provide the 53.26provider or enrollee with the criteria used to determine the necessity, appropriateness, 53.27and efficacy of the health care service and identify the database, professional treatment 53.28parameter, or other basis for the criteria. Reasons for a determination not to certify may 53.29include, among other things, the lack of adequate information to certify after a reasonable 53.30attempt has been made to contact the provider or enrollee. 53.31(d) When an initial determination is made not to certify, the written notification must 53.32inform the enrollee and the attending health care professional of the right to submit an 53.33appeal to the internal appeal process described in section 62M.06 and the procedure for 53.34initiating the internal appeal. new text begin The written notice shall be provided in a culturally and new text end 53.35 new text begin linguistically appropriate manner consistent with the provisions of the Affordable Care new text end 53.36 new text begin Act as defined under section 62A.011, subdivision 1a. new text end 54.1 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 54.2    Sec. 59. Minnesota Statutes 2012, section 62M.06, subdivision 1, is amended to read: 54.3    Subdivision 1. Procedures for appeal. new text begin (a) new text end A utilization review organization must 54.4have written procedures for appeals of determinations not to certify. The right to appeal 54.5must be available to the enrollee and to the attending health care professional. 54.6 new text begin (b) The enrollee shall be allowed to review the information relied upon in the course new text end 54.7 new text begin of the appeal, present evidence and testimony as part of the appeals process, and receive new text end 54.8 new text begin continued coverage pending the outcome of the appeals process. This paragraph does new text end 54.9 new text begin not apply to managed care plans or county-based purchasing plans serving state public new text end 54.10 new text begin health care program enrollees under section 256B.69, 256B.692, or chapter 256L, or to new text end 54.11 new text begin grandfathered plans as defined under section 62A.011, subdivision 1c. Nothing in this new text end 54.12 new text begin paragraph shall be construed to limit or restrict the appeal rights of state public health care new text end 54.13 new text begin program enrollees provided under section 256.045 and Code of Federal Regulations, title new text end 54.14 new text begin 42, section 438.420(d). new text end 54.15 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 54.16    Sec. 60. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 54.17to read: 54.18     new text begin Subd. 1a. new text end new text begin Affordable Care Act. new text end new text begin "Affordable Care Act" means the Affordable Care new text end 54.19 new text begin Act as defined in section 62A.011, subdivision 1a. new text end 54.20 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 54.21    Sec. 61. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 54.22to read: 54.23     new text begin Subd. 1b. new text end new text begin Bona fide association. new text end new text begin "Bona fide association" means an association that new text end 54.24 new text begin meets all of the following criteria: new text end 54.25 new text begin (1) serves a single profession that requires a significant amount of education, training, new text end 54.26 new text begin or experience, or a license or certificate from a state authority to practice that profession; new text end 54.27 new text begin (2) has been actively in existence for five years; new text end 54.28 new text begin (3) has a constitution and bylaws or other analogous governing documents; new text end 54.29 new text begin (4) has been formed and maintained in good faith for purposes other than obtaining new text end 54.30 new text begin insurance; new text end 54.31 new text begin (5) is not owned or controlled by a health plan company or affiliated with a health new text end 54.32 new text begin plan company; new text end 55.1 new text begin (6) does not condition membership in the association on any health status-related new text end 55.2 new text begin factor; new text end 55.3 new text begin (7) has at least 1,000 members if it is a national association, 500 members if it is a new text end 55.4 new text begin state association, or 200 members if it is a local association; new text end 55.5 new text begin (8) all members and dependents of members are eligible for coverage regardless of new text end 55.6 new text begin any health status-related factor; new text end 55.7 new text begin (9) does not make health plans offered through the association available other than new text end 55.8 new text begin in connection with a member of the association; new text end 55.9 new text begin (10) is governed by a board of directors and sponsors an annual meeting of its new text end 55.10 new text begin members; and new text end 55.11 new text begin (11) produces only market association memberships, accepts applications for new text end 55.12 new text begin membership, or signs up members in the professional association where the subject new text end 55.13 new text begin individuals are actively engaged in, or directly related to, the profession represented new text end 55.14 new text begin by the association. new text end 55.15 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 55.16    Sec. 62. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 55.17to read: 55.18     new text begin Subd. 2b. new text end new text begin Grandfathered plan. new text end new text begin "Grandfathered plan" means a health plan as new text end 55.19 new text begin defined in section 62A.011, subdivision 1b. new text end 55.20    Sec. 63. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 55.21to read: 55.22     new text begin Subd. 2c. new text end new text begin Group health plan. new text end new text begin "Group health plan" means a group health plan as new text end 55.23 new text begin defined in section 62A.011, subdivision 1c. new text end 55.24    Sec. 64. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 55.25to read: 55.26     new text begin Subd. 4b. new text end new text begin Individual health plan. new text end new text begin "Individual health plan" means an individual new text end 55.27 new text begin health plan as defined in section 62A.011, subdivision 4. new text end 55.28    Sec. 65. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 55.29to read: 55.30     new text begin Subd. 7. new text end new text begin Life-threatening condition. new text end new text begin "Life-threatening condition" means a disease new text end 55.31 new text begin or condition from which the likelihood of death is probable unless the course of the new text end 55.32 new text begin disease or condition is interrupted. new text end 56.1 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 56.2    Sec. 66. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 56.3to read: 56.4     new text begin Subd. 8. new text end new text begin Primary care provider. new text end new text begin "Primary care provider" means a health care new text end 56.5 new text begin professional who specializes in the practice of family medicine, general internal medicine, new text end 56.6 new text begin obstetrics and gynecology, or general pediatrics and is a licensed physician, a licensed and new text end 56.7 new text begin certified advanced practice registered nurse, or a licensed physician assistant. new text end 56.8 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 56.9    Sec. 67. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision 56.10to read: 56.11     new text begin Subd. 9. new text end new text begin Dependent child to the limiting age. new text end new text begin "Dependent child to the limiting new text end 56.12 new text begin age" or "dependent children to the limiting age" means those individuals who are eligible new text end 56.13 new text begin and covered as a dependent child under the terms of a health plan who have not yet new text end 56.14 new text begin attained 26 years of age. A health plan company must not deny or restrict eligibility new text end 56.15 new text begin for a dependent child to the limiting age based on financial dependency, residency, new text end 56.16 new text begin marital status, or student status. For coverage under plans offered by the Minnesota new text end 56.17 new text begin Comprehensive Health Association, dependent to the limiting age means dependent new text end 56.18 new text begin as defined in section 62A.302, subdivision 3. Notwithstanding the provisions in this new text end 56.19 new text begin subdivision, a health plan may include: new text end 56.20 new text begin (1) eligibility requirements regarding the absence of other health plan coverage as new text end 56.21 new text begin permitted by the Affordable Care Act for grandfathered plan coverage; or new text end 56.22 new text begin (2) an age greater than 26 in its policy, contract, or certificate of coverage. new text end 56.23 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 56.24    Sec. 68. Minnesota Statutes 2012, section 62Q.021, is amended to read: 56.2562Q.021 FEDERAL ACT; COMPLIANCE REQUIRED. 56.26     new text begin Subdivision 1. new text end new text begin Compliance with 1996 federal law. new text end Each health plan company shall 56.27comply with the federal Health Insurance Portability and Accountability Act of 1996, 56.28including any federal regulations adopted under that act, to the extent that it imposes a 56.29requirement that applies in this state and that is not also required by the laws of this state. 56.30This section does not require compliance with any provision of the federal act prior to 56.31the effective date provided for that provision in the federal act. The commissioner shall 56.32enforce this section new text begin subdivision new text end . 57.1     new text begin Subd. 2. new text end new text begin Compliance with 2010 federal law. new text end new text begin Each health plan company shall new text end 57.2 new text begin comply with the Affordable Care Act to the extent that it imposes a requirement that new text end 57.3 new text begin applies in this state but is not required under the laws of this state. This section does not new text end 57.4 new text begin require compliance with any provision of the Affordable Care Act before the effective new text end 57.5 new text begin date provided for that provision in the Affordable Care Act. The commissioner shall new text end 57.6 new text begin enforce this subdivision. new text end 57.7 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 57.8    Sec. 69. Minnesota Statutes 2012, section 62Q.17, subdivision 6, is amended to read: 57.9    Subd. 6. Employer-based purchasing pools. Employer-based purchasing 57.10pools must, with respect to small employers as defined in section 62L.02, meet all the 57.11requirements of chapter 62L. The experience of the pool must be pooled and the rates 57.12blended across all groups. Pools may decide to create tiers within the pool, based on 57.13experience of group members. These tiers must be designed within the requirements 57.14of section . The governing structure may establish criteria limiting movement 57.15between tiers. Tiers must be phased out within two years of the pool's creation. 57.16 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 57.17    Sec. 70. Minnesota Statutes 2012, section 62Q.18, is amended by adding a subdivision 57.18to read: 57.19     new text begin Subd. 8. new text end new text begin Guaranteed issue. new text end new text begin No health plan company shall offer, sell, or issue new text end 57.20 new text begin any health plan that does not make coverage available on a guaranteed issue basis in new text end 57.21 new text begin accordance with the Affordable Care Act. new text end 57.22 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 57.23    Sec. 71. new text begin [62Q.186] PROHIBITION ON RESCISSIONS OF HEALTH PLANS. new text end 57.24     new text begin Subdivision 1. new text end new text begin Definitions. new text end new text begin (a) "Rescission" means a cancellation or discontinuance new text end 57.25 new text begin of coverage under a health plan that has a retroactive effect. new text end 57.26 new text begin (b) "Rescission" does not include: new text end 57.27 new text begin (1) a cancellation or discontinuance of coverage under a health plan if: new text end 57.28 new text begin (i) the cancellation or discontinuance of coverage has only a prospective effect; or new text end 57.29 new text begin (ii) the cancellation or discontinuance of coverage is effective retroactively to the new text end 57.30 new text begin extent it is attributable to a failure to timely pay required premiums or contributions new text end 57.31 new text begin toward the cost of coverage; or new text end 58.1 new text begin (2) when the health plan covers only active employees and, if applicable, new text end 58.2 new text begin dependents and those covered under continuation coverage provisions, the employee new text end 58.3 new text begin pays no premiums for coverage after termination of employment and the cancellation or new text end 58.4 new text begin discontinuance of coverage is effective retroactively back to the date of termination of new text end 58.5 new text begin employment due to a delay in administrative record keeping. new text end 58.6     new text begin Subd. 2. new text end new text begin Prohibition on rescissions. new text end new text begin (a) A health plan company shall not rescind new text end 58.7 new text begin coverage under a health plan with respect to an individual, including a group to which new text end 58.8 new text begin the individual belongs or family coverage in which the individual is included, after the new text end 58.9 new text begin individual is covered under the health plan, unless: new text end 58.10 new text begin (1) the individual, or a person seeking coverage on behalf of the individual, performs new text end 58.11 new text begin an act, practice, or omission that constitutes fraud; or new text end 58.12 new text begin (2) the individual makes an intentional misrepresentation or omission of material new text end 58.13 new text begin fact, as prohibited by the terms of the health plan. new text end 58.14 new text begin For purposes of this section, a person seeking coverage on behalf of an individual new text end 58.15 new text begin does not include an insurance producer or employee or authorized representative of the new text end 58.16 new text begin health carrier. new text end 58.17 new text begin (b) This section does not apply to any benefits classified as excepted benefits under new text end 58.18 new text begin United States Code, title 42, section 300gg-91(c), or regulations enacted thereunder new text end 58.19 new text begin from time to time. new text end 58.20     new text begin Subd. 3. new text end new text begin Notice required. new text end new text begin A health plan company shall provide at least 30 days' new text end 58.21 new text begin advance written notice to each individual who would be affected by the proposed rescission new text end 58.22 new text begin of coverage before coverage under the health plan may be terminated retroactively. new text end 58.23     new text begin Subd. 4. new text end new text begin Compliance with other restrictions on rescissions. new text end new text begin Nothing in this new text end 58.24 new text begin section allows rescission if rescission would otherwise be prohibited under section new text end 58.25 new text begin 62A.04, subdivision 2, clause (2), or 62A.615. new text end 58.26 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 58.27    Sec. 72. Minnesota Statutes 2012, section 62Q.23, is amended to read: 58.2862Q.23 GENERAL SERVICES. 58.29(a) Health plan companies shall comply with all continuation and conversion of 58.30coverage requirements applicable to health maintenance organizations under state or 58.31federal law. 58.32(b) Health plan companies shall comply with sections 62A.047, 62A.27, and any 58.33other coverage required under chapter 62A of newborn infants, dependent children who 58.34do not reside with a covered person new text begin to the limiting age as defined in section 62Q.01, new text end 59.1 new text begin subdivision 9 new text end , disabled children and dependents new text begin dependent children new text end , and adopted children. 59.2A health plan company providing dependent coverage shall comply with section 62A.302. 59.3(c) Health plan companies shall comply with the equal access requirements of 59.4section 62A.15. 59.5 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 59.6    Sec. 73. Minnesota Statutes 2012, section 62Q.43, subdivision 2, is amended to read: 59.7    Subd. 2. Access requirement. Every closed-panel health plan must allow enrollees 59.8who are full-time students under the age of 25 new text begin 26 new text end years to change their designated clinic or 59.9physician at least once per month, as long as the clinic or physician is part of the health 59.10plan company's statewide clinic or physician network. A health plan company shall not 59.11charge enrollees who choose this option higher premiums or cost sharing than would 59.12otherwise apply to enrollees who do not choose this option. A health plan company may 59.13require enrollees to provide 15 days' written notice of intent to change their designated 59.14clinic or physician. 59.15 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 59.16    Sec. 74. new text begin [62Q.46] PREVENTIVE ITEMS AND SERVICES. new text end 59.17     new text begin Subdivision 1. new text end new text begin Coverage for preventive items and services. new text end new text begin (a) "Preventive items new text end 59.18 new text begin and services" has the meaning specified in the Affordable Care Act. new text end 59.19 new text begin (b) A health plan company must provide coverage for preventive items and services new text end 59.20 new text begin at a participating provider without imposing cost-sharing requirements, including a new text end 59.21 new text begin deductible, coinsurance, or co-payment. Nothing in this section prohibits a health new text end 59.22 new text begin plan company that has a network of providers from excluding coverage or imposing new text end 59.23 new text begin cost-sharing requirements for preventive items or services that are delivered by an new text end 59.24 new text begin out-of-network provider. new text end 59.25 new text begin (c) A health plan company is not required to provide coverage for any items or new text end 59.26 new text begin services specified in any recommendation or guideline described in paragraph (a) if the new text end 59.27 new text begin recommendation or guideline is no longer included as a preventive item or service as new text end 59.28 new text begin defined in paragraph (a). Annually, a health plan company must determine whether any new text end 59.29 new text begin additional items or services must be covered without cost-sharing requirements or whether new text end 59.30 new text begin any items or services are no longer required to be covered. new text end 59.31 new text begin (d) Nothing in this section prevents a health plan company from using reasonable new text end 59.32 new text begin medical management techniques to determine the frequency, method, treatment, or setting new text end 60.1 new text begin for a preventive item or service to the extent not specified in the recommendation or new text end 60.2 new text begin guideline. new text end 60.3 new text begin (e) This section does not apply to grandfathered plans. new text end 60.4 new text begin (f) This section does not apply to plans offered by the Minnesota Comprehensive new text end 60.5 new text begin Health Association. new text end 60.6     new text begin Subd. 2. new text end new text begin Coverage for office visits in conjunction with preventive items and new text end 60.7 new text begin services. new text end new text begin (a) A health plan company may impose cost-sharing requirements with respect new text end 60.8 new text begin to an office visit if a preventive item or service is billed separately or is tracked separately new text end 60.9 new text begin as individual encounter data from the office visit. new text end 60.10 new text begin (b) A health plan company must not impose cost-sharing requirements with respect new text end 60.11 new text begin to an office visit if a preventive item or service is not billed separately or is not tracked new text end 60.12 new text begin separately as individual encounter data from the office visit and the primary purpose of the new text end 60.13 new text begin office visit is the delivery of the preventive item or service. new text end 60.14 new text begin (c) A health plan company may impose cost-sharing requirements with respect to new text end 60.15 new text begin an office visit if a preventive item or service is not billed separately or is not tracked new text end 60.16 new text begin separately as individual encounter data from the office visit and the primary purpose of the new text end 60.17 new text begin office visit is not the delivery of the preventive item or service. new text end 60.18     new text begin Subd. 3. new text end new text begin Additional services not prohibited. new text end new text begin Nothing in this section prohibits a new text end 60.19 new text begin health plan company from providing coverage for preventive items and services in addition new text end 60.20 new text begin to those specified in the Affordable Care Act, or from denying coverage for preventive new text end 60.21 new text begin items and services that are not recommended as preventive items and services under the new text end 60.22 new text begin Affordable Care Act. A health plan company may impose cost-sharing requirements for a new text end 60.23 new text begin treatment not described in the Affordable Care Act even if the treatment results from a new text end 60.24 new text begin preventive item or service described in the Affordable Care Act. new text end 60.25 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 60.26    Sec. 75. Minnesota Statutes 2012, section 62Q.47, is amended to read: 60.2762Q.47 ALCOHOLISM, MENTAL HEALTH, AND CHEMICAL 60.28DEPENDENCY SERVICES. 60.29    (a) All health plans, as defined in section 62Q.01, that provide coverage for 60.30alcoholism, mental health, or chemical dependency services, must comply with the 60.31requirements of this section. 60.32    (b) Cost-sharing requirements and benefit or service limitations for outpatient 60.33mental health and outpatient chemical dependency and alcoholism services, except for 60.34persons placed in chemical dependency services under Minnesota Rules, parts 9530.6600 61.1to 9530.6660, must not place a greater financial burden on the insured or enrollee, or be 61.2more restrictive than those requirements and limitations for outpatient medical services. 61.3    (c) Cost-sharing requirements and benefit or service limitations for inpatient hospital 61.4mental health and inpatient hospital and residential chemical dependency and alcoholism 61.5services, except for persons placed in chemical dependency services under Minnesota 61.6Rules, parts 9530.6600 to 9530.6660, must not place a greater financial burden on the 61.7insured or enrollee, or be more restrictive than those requirements and limitations for 61.8inpatient hospital medical services. 61.9     new text begin (d) All health plans must meet the requirements of the federal Mental Health Parity new text end 61.10 new text begin Act of 1996, Public Law 104-204; Paul Wellstone and Pete Domenici Mental Health new text end 61.11 new text begin Parity and Addiction Equity Act of 2008; the Affordable Care Act; and any amendments new text end 61.12 new text begin to, and federal guidance or regulations issued under, those acts. new text end 61.13 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 61.14    Sec. 76. Minnesota Statutes 2012, section 62Q.52, is amended to read: 61.1562Q.52 DIRECT ACCESS TO OBSTETRIC AND GYNECOLOGIC 61.16SERVICES. 61.17     new text begin Subdivision 1. new text end new text begin Direct access. new text end (a) Health plan companies shall allow female 61.18enrollees direct access to obstetricians and gynecologists new text begin providers who specialize in new text end 61.19 new text begin obstetrics and gynecology new text end for the following services: 61.20(1) annual preventive health examinations, which shall include a gynecologic 61.21examination, and any subsequent obstetric or gynecologic visits determined to be medically 61.22necessary by the examining obstetrician or gynecologist, based upon the findings of the 61.23examination new text begin evaluation and necessary treatment for obstetric conditions or emergencies new text end ; 61.24(2) maternity care; and 61.25(3) evaluation and necessary treatment for acute gynecologic conditions or 61.26emergencies new text begin , including annual preventive health examinations new text end . 61.27(b) For purposes of this section, "direct access" means that a female enrollee may 61.28obtain the obstetric and gynecologic services specified in paragraph (a) from obstetricians 61.29and gynecologists new text begin providers who specialize in obstetrics and gynecology new text end in the enrollee's 61.30network without a referral from, or prior approval through new text begin a primary care provider new text end , 61.31another physician, the health plan company, or its representatives. 61.32 new text begin (c) The health plan company shall treat the provision of obstetrical and gynecological new text end 61.33 new text begin care and the ordering of related obstetrical and gynecological items and services, pursuant new text end 62.1 new text begin to paragraph (a), by a participating health care provider who specializes in obstetrics or new text end 62.2 new text begin gynecology as the authorization of a primary care provider. new text end 62.3 new text begin (d) The health plan company may require the health care provider to agree to new text end 62.4 new text begin otherwise adhere to the health plan company's policies and procedures, including new text end 62.5 new text begin procedures for obtaining prior authorization and for providing services in accordance with new text end 62.6 new text begin a treatment plan, if any, approved by the health plan company. new text end 62.7(c) new text begin (e) new text end Health plan companies shall not require higher co-payments, coinsurance, 62.8deductibles, or other enrollee cost-sharing for direct access. 62.9(d) new text begin (f) new text end This section applies only to services described in paragraph (a) that are 62.10covered by the enrollee's coverage, but coverage of a preventive health examination for 62.11female enrollees must not exclude coverage of a gynecologic examination. 62.12 new text begin (g) For purposes of this section, a health care provider who specializes in obstetrics new text end 62.13 new text begin or gynecology means any individual, including an individual other than a physician, who new text end 62.14 new text begin is authorized under state law to provide obstetrical or gynecological care. new text end 62.15 new text begin (h) This section does not: new text end 62.16 new text begin (1) waive any exclusions of coverage under the terms and conditions of the health new text end 62.17 new text begin plan with respect to coverage of obstetrical or gynecological care; or new text end 62.18 new text begin (2) preclude the health plan company from requiring that the participating health new text end 62.19 new text begin care provider providing obstetrical or gynecological care notify the primary care provider new text end 62.20 new text begin or the health plan company of treatment decisions. new text end 62.21     new text begin Subd. 2. new text end new text begin Notice. new text end new text begin A health plan company shall provide notice to enrollees of the new text end 62.22 new text begin provisions of subdivision 1 in accordance with the requirements of the Affordable Care Act. new text end 62.23     new text begin Subd. 3. new text end new text begin Enforcement. new text end new text begin The commissioner of health shall enforce this section. new text end 62.24 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 62.25    Sec. 77. new text begin [62Q.526] COVERAGE FOR PARTICIPATION IN APPROVED new text end 62.26 new text begin CLINICAL TRIALS. new text end 62.27     new text begin Subdivision 1. new text end new text begin Definitions. new text end new text begin As used in this section, the following definitions apply: new text end 62.28 new text begin (a) "Approved clinical trial" means a phase I, phase II, phase III, or phase IV clinical new text end 62.29 new text begin trial that is conducted in relation to the prevention, detection, or treatment of cancer or new text end 62.30 new text begin a life-threatening condition and is not designed exclusively to test toxicity or disease new text end 62.31 new text begin pathophysiology and must be: new text end 62.32 new text begin (1) conducted under an investigational new drug application reviewed by the United new text end 62.33 new text begin States Food and Drug Administration (FDA); new text end 62.34 new text begin (2) exempt from obtaining an investigational new drug application; or new text end 62.35 new text begin (3) approved or funded by: new text end 63.1 new text begin (i) the National Institutes of Health (NIH), the Centers for Disease Control and new text end 63.2 new text begin Prevention, the Agency for Health Care Research and Quality, the Centers for Medicare new text end 63.3 new text begin and Medicaid Services, or a cooperating group or center of any of the entities described in new text end 63.4 new text begin this item; new text end 63.5 new text begin (ii) a cooperative group or center of the United States Department of Defense or the new text end 63.6 new text begin United States Department of Veterans Affairs; new text end 63.7 new text begin (iii) a qualified nongovernmental research entity identified in the guidelines issued new text end 63.8 new text begin by the NIH for center support grants; or new text end 63.9 new text begin (iv) the United States Departments of Veterans Affairs, Defense, or Energy if the new text end 63.10 new text begin trial has been reviewed or approved through a system of peer review determined by the new text end 63.11 new text begin secretary to: new text end 63.12 new text begin (A) be comparable to the system of peer review of studies and investigations used by new text end 63.13 new text begin the NIH; and new text end 63.14 new text begin (B) provide an unbiased scientific review by qualified individuals who have no new text end 63.15 new text begin interest in the outcome of the review. new text end 63.16 new text begin (b) "Qualified individual" means an individual with health plan coverage who is new text end 63.17 new text begin eligible to participate in an approved clinical trial according to the trial protocol for the new text end 63.18 new text begin treatment of cancer or a life-threatening condition because: new text end 63.19 new text begin (1) the referring health care professional is participating in the trial and has new text end 63.20 new text begin concluded that the individual's participation in the trial would be appropriate; or new text end 63.21 new text begin (2) the individual provides medical and scientific information establishing that new text end 63.22 new text begin the individual's participation in the trial is appropriate because the individual meets the new text end 63.23 new text begin conditions described in the trial protocol. new text end 63.24 new text begin (c)(1) "Routine patient costs" includes all items and services covered by the health new text end 63.25 new text begin benefit plan of individual market health insurance coverage when the items or services new text end 63.26 new text begin are typically covered for an enrollee who is not a qualified individual enrolled in an new text end 63.27 new text begin approved clinical trial. new text end 63.28 new text begin (2) Routine patient costs does not include: new text end 63.29 new text begin (i) an investigational item, device, or service that is part of the trial; new text end 63.30 new text begin (ii) an item or service provided solely to satisfy data collection and analysis needs for new text end 63.31 new text begin the trial if the item or service is not used in the direct clinical management of the patient; new text end 63.32 new text begin (iii) a service that is clearly inconsistent with widely accepted and established new text end 63.33 new text begin standards of care for the individual's diagnosis; or new text end 63.34 new text begin (iv) an item or service customarily provided and paid for by the sponsor of a trial. new text end 63.35     new text begin Subd. 2. new text end new text begin Prohibited acts. new text end new text begin A health plan company that offers a health plan to a new text end 63.36 new text begin Minnesota resident may not: new text end 64.1 new text begin (1) deny participation by a qualified individual in an approved clinical trial; new text end 64.2 new text begin (2) deny, limit, or impose additional conditions on the coverage of routine patient new text end 64.3 new text begin costs for items or services furnished in connection with participation in the trial; or new text end 64.4 new text begin (3) discriminate against an individual on the basis of an individual's participation in new text end 64.5 new text begin an approved clinical trial. new text end 64.6     new text begin Subd. 3. new text end new text begin Network plan conditions. new text end new text begin A health plan company that designates a new text end 64.7 new text begin network or networks of contracted providers may require a qualified individual who new text end 64.8 new text begin wishes to participate in an approved clinical trial to participate in a trial that is offered new text end 64.9 new text begin through a health care provider who is part of the plan's network if the provider is new text end 64.10 new text begin participating in the trial and the provider accepts the individual as a participant in the trial. new text end 64.11     new text begin Subd. 4. new text end new text begin Application to clinical trials outside of the state. new text end new text begin This section applies new text end 64.12 new text begin to a qualified individual residing in this state who participates in an approved clinical new text end 64.13 new text begin trial that is conducted outside of this state. new text end 64.14     new text begin Subd. 5. new text end new text begin Construction. new text end new text begin (a) This section shall not be construed to require a health new text end 64.15 new text begin plan company offering health plan coverage through a network or networks of contracted new text end 64.16 new text begin providers to provide benefits for routine patient costs if the services are provided outside new text end 64.17 new text begin of the plan's network unless the out-of-network benefits are otherwise provided under new text end 64.18 new text begin the coverage. new text end 64.19 new text begin (b) This section shall not be construed to limit a health plan company's coverage new text end 64.20 new text begin with respect to clinical trials. new text end 64.21 new text begin (c) This section shall apply to all health plan companies offering a health plan to a new text end 64.22 new text begin Minnesota resident, unless otherwise amended by federal regulations under the Affordable new text end 64.23 new text begin Care Act. new text end 64.24 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 64.25    Sec. 78. Minnesota Statutes 2012, section 62Q.55, is amended to read: 64.2662Q.55 EMERGENCY SERVICES. 64.27     new text begin Subdivision 1. new text end new text begin Access to emergency services. new text end (a) Enrollees have the right to 64.28available and accessible emergency services, 24 hours a day and seven days a week. 64.29The health plan company shall inform its enrollees how to obtain emergency care and, 64.30if prior authorization for emergency services is required, shall make available a toll-free 64.31number, which is answered 24 hours a day, to answer questions about emergency services 64.32and to receive reports and provide authorizations, where appropriate, for treatment of 64.33emergency medical conditions. Emergency services shall be covered whether provided by 64.34participating or nonparticipating providers and whether provided within or outside the 65.1health plan company's service area. In reviewing a denial for coverage of emergency 65.2services, the health plan company shall take the following factors into consideration: 65.3(1) a reasonable layperson's belief that the circumstances required immediate medical 65.4care that could not wait until the next working day or next available clinic appointment; 65.5(2) the time of day and day of the week the care was provided; 65.6(3) the presenting symptoms, including, but not limited to, severe pain, to ensure 65.7that the decision to reimburse the emergency care is not made solely on the basis of the 65.8actual diagnosis; 65.9(4) the enrollee's efforts to follow the health plan company's established procedures 65.10for obtaining emergency care; and 65.11(5) any circumstances that precluded use of the health plan company's established 65.12procedures for obtaining emergency care. 65.13(b) The health plan company may require enrollees to notify the health plan 65.14company of nonreferred emergency care as soon as possible, but not later than 48 hours, 65.15after the emergency care is initially provided. However, emergency care which would 65.16have been covered under the contract had notice been provided within the set time frame 65.17must be covered. 65.18(c) Notwithstanding paragraphs (a) and (b), a health plan company, health insurer, or 65.19health coverage plan that is in compliance with the rules regarding accessibility of services 65.20adopted under section 62D.20 is in compliance with this section. 65.21     new text begin Subd. 2. new text end new text begin Emergency medical condition. new text end new text begin For purposes of this section, "emergency new text end 65.22 new text begin medical condition" means a medical condition manifesting itself by acute symptoms of new text end 65.23 new text begin sufficient severity, including severe pain, such that a prudent layperson, who possesses new text end 65.24 new text begin an average knowledge of health and medicine, could reasonably expect the absence of new text end 65.25 new text begin immediate medical attention to result in a condition described in clause (i), (ii), or (iii), of new text end 65.26 new text begin section 1867(e)(1)(A) of the Social Security Act. new text end 65.27     new text begin Subd. 3. new text end new text begin Emergency services. new text end new text begin As used in this section, "emergency services" means, new text end 65.28 new text begin with respect to an emergency medical condition: new text end 65.29 new text begin (1) a medical screening examination, as required under section 1867 of the Social new text end 65.30 new text begin Security Act, that is within the capability of the emergency department of a hospital, new text end 65.31 new text begin including ancillary services routinely available to the emergency department to evaluate new text end 65.32 new text begin such emergency medical condition; and new text end 65.33 new text begin (2) within the capabilities of the staff and facilities available at the hospital, such new text end 65.34 new text begin further medical examination and treatment as are required under section 1867 of the new text end 65.35 new text begin Social Security Act to stabilize the patient. new text end 66.1     new text begin Subd. 4. new text end new text begin Stabilize. new text end new text begin For purposes of this section, "stabilize," with respect to an new text end 66.2 new text begin emergency medical condition, has the meaning given in section 1867(e)(3) of the Social new text end 66.3 new text begin Security Act, United States Code, title 42, section 1395dd(e)(3). new text end 66.4     new text begin Subd. 5. new text end new text begin Coverage restrictions or limitations. new text end new text begin If emergency services are provided new text end 66.5 new text begin by a nonparticipating provider, with or without prior authorization, the health plan new text end 66.6 new text begin company shall not impose coverage restrictions or limitations that are more restrictive new text end 66.7 new text begin than apply to emergency services received from a participating provider. Cost-sharing new text end 66.8 new text begin requirements that apply to emergency services received out-of-network must be the same new text end 66.9 new text begin as the cost-sharing requirements that apply to services received in-network. new text end 66.10 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 66.11    Sec. 79. new text begin [62Q.57] DESIGNATION OF PRIMARY CARE PROVIDER. new text end 66.12     new text begin Subdivision 1. new text end new text begin Choice of primary care provider. new text end new text begin (a) If a health plan company new text end 66.13 new text begin offering a group health plan, or an individual health plan that is not a grandfathered plan, new text end 66.14 new text begin requires or provides for the designation by an enrollee of a participating primary care new text end 66.15 new text begin provider, the health plan company shall permit each enrollee to: new text end 66.16 new text begin (1) designate any participating primary care provider available to accept the new text end 66.17 new text begin enrollee; and new text end 66.18 new text begin (2) for a child, designate any participating physician who specializes in pediatrics as new text end 66.19 new text begin the child's primary care provider and is available to accept the child. new text end 66.20 new text begin (b) This section does not waive any exclusions of coverage under the terms and new text end 66.21 new text begin conditions of the health plan with respect to coverage of pediatric care. new text end 66.22     new text begin Subd. 2. new text end new text begin Notice. new text end new text begin A health plan company shall provide notice to enrollees of the new text end 66.23 new text begin provisions of subdivision 1 in accordance with the requirements of the Affordable Care Act. new text end 66.24     new text begin Subd. 3. new text end new text begin Enforcement. new text end new text begin The commissioner shall enforce this section. new text end 66.25 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 66.26    Sec. 80. new text begin [62Q.677] LIFETIME AND ANNUAL LIMITS. new text end 66.27     new text begin Subdivision 1. new text end new text begin Applicability and scope. new text end new text begin Except as provided in subdivision 2, new text end 66.28 new text begin this section applies to a health plan company providing coverage under an individual or new text end 66.29 new text begin group health plan. For purposes of this section, essential health benefits is defined under new text end 66.30 new text begin section 62Q.81. new text end 66.31     new text begin Subd. 2. new text end new text begin Grandfathered plan limits. new text end new text begin (a) The prohibition on lifetime limits applies new text end 66.32 new text begin to grandfathered plans providing individual health plan coverage or group health plan new text end 66.33 new text begin coverage. new text end 67.1 new text begin (b) The prohibition and limits on annual limits apply to grandfathered plans new text end 67.2 new text begin providing group health plan coverage, but do not apply to grandfathered plans providing new text end 67.3 new text begin individual health plan coverage. new text end 67.4     new text begin Subd. 3. new text end new text begin Prohibition on lifetime and annual limits. new text end new text begin (a) Except as provided in new text end 67.5 new text begin subdivisions 4 and 5, a health plan company offering coverage under an individual or new text end 67.6 new text begin group health plan shall not establish a lifetime limit on the dollar amount of essential new text end 67.7 new text begin health benefits for any individual. new text end 67.8 new text begin (b) Except as provided in subdivisions 4, 5, and 6, a health plan company shall new text end 67.9 new text begin not establish any annual limit on the dollar amount of essential health benefits for any new text end 67.10 new text begin individual. new text end 67.11     new text begin Subd. 4. new text end new text begin Nonessential benefits; out-of-network providers. new text end new text begin (a) Subdivision 3 does new text end 67.12 new text begin not prevent a health plan company from placing annual or lifetime dollar limits for any new text end 67.13 new text begin individual on specific covered benefits that are not essential health benefits as defined in new text end 67.14 new text begin section 62Q.81, subdivision 4, to the extent that the limits are otherwise permitted under new text end 67.15 new text begin applicable federal or state law. new text end 67.16 new text begin (b) Subdivision 3 does not prevent a health plan company from placing an annual or new text end 67.17 new text begin lifetime limit for services provided by out-of-network providers. new text end 67.18     new text begin Subd. 5. new text end new text begin Excluded benefits. new text end new text begin This section does not prohibit a health plan company new text end 67.19 new text begin from excluding all benefits for a given condition. new text end 67.20     new text begin Subd. 6. new text end new text begin Annual limits prior to January 1, 2014. new text end new text begin For plan or policy years new text end 67.21 new text begin beginning before January 1, 2014, for any individual, a health plan company may establish new text end 67.22 new text begin an annual limit on the dollar amount of benefits that are essential health benefits provided new text end 67.23 new text begin the limit is no less than the following: new text end 67.24 new text begin (1) for a plan or policy year beginning after September 22, 2010, but before new text end 67.25 new text begin September 23, 2011, $750,000; new text end 67.26 new text begin (2) for a plan or policy year beginning after September 22, 2011, but before new text end 67.27 new text begin September 23, 2012, $1,250,000; and new text end 67.28 new text begin (3) for a plan or policy year beginning after September 22, 2012, but before January new text end 67.29 new text begin 1, 2014, $2,000,000. new text end 67.30 new text begin In determining whether an individual has received benefits that meet or exceed the new text end 67.31 new text begin allowable limits, a health plan company shall take into account only essential health new text end 67.32 new text begin benefits. new text end 67.33     new text begin Subd. 7. new text end new text begin Waivers. new text end new text begin For plan or policy years beginning before January 1, 2014, a new text end 67.34 new text begin health plan is exempt from the annual limit requirements if the health plan is approved for new text end 67.35 new text begin a waiver from the requirements by the United States Department of Health and Human new text end 68.1 new text begin Services, but the exemption only applies for the specified period of time that the waiver new text end 68.2 new text begin from the United States Department of Health and Human Services is applicable. new text end 68.3     new text begin Subd. 8. new text end new text begin Notices. new text end new text begin (a) At the time a health plan company receives a waiver from the new text end 68.4 new text begin United States Department of Health and Human Services, the health plan company shall new text end 68.5 new text begin notify prospective applicants and affected policyholders and the commissioner in each new text end 68.6 new text begin state where prospective applicants and any affected insured are known to reside. new text end 68.7 new text begin (b) At the time the waiver expires or is otherwise no longer in effect, the health plan new text end 68.8 new text begin company shall notify affected policyholders and the commissioner in each state where new text end 68.9 new text begin any affected insured is known to reside. new text end 68.10     new text begin Subd. 9. new text end new text begin Reinstatement. new text end new text begin A health plan company shall comply with all provisions of new text end 68.11 new text begin the Affordable Care Act with regard to reinstatement of coverage for individuals whose new text end 68.12 new text begin coverage or benefits under a health plan ended by reason of reaching a lifetime dollar limit new text end 68.13 new text begin on the dollar value of all benefits for the individual. new text end 68.14     new text begin Subd. 10. new text end new text begin Compliance. new text end new text begin This section does not require compliance with any new text end 68.15 new text begin provision of the Affordable Care Act before the effective date provided for that provision new text end 68.16 new text begin in the Affordable Care Act. The commissioner shall enforce this section. new text end 68.17 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 68.18    Sec. 81. Minnesota Statutes 2012, section 62Q.68, subdivision 1, is amended to read: 68.19    Subdivision 1. Application. For purposes of sections 62Q.68 to 62Q.72, the terms 68.20defined in this section have the meanings given them. For purposes of sections 62Q.69 68.21and 62Q.70, the term "health plan company" does not include an insurance company 68.22licensed under chapter 60A to offer, sell, or issue a policy of accident and sickness 68.23insurance as defined in section 62A.01 or a nonprofit health service plan corporation 68.24regulated under chapter 62C that only provides dental coverage or vision coverage. For 68.25purposes of sections 62Q.69 through 62Q.73, the term "health plan company" does 68.26not include the Comprehensive Health Association created under chapter 62E. new text begin Section new text end 68.27 new text begin 62Q.70 does not apply to individual coverage. However, a health plan company offering new text end 68.28 new text begin individual coverage may, pursuant to section 62Q.69, subdivision 3, paragraph (c), follow new text end 68.29 new text begin the process outlined in section 62Q.70. new text end 68.30 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 68.31    Sec. 82. Minnesota Statutes 2012, section 62Q.69, subdivision 3, is amended to read: 68.32    Subd. 3. Notification of complaint decisions. (a) The health plan company must 68.33notify the complainant in writing of its decision and the reasons for it as soon as practical 69.1but in no case later than 30 days after receipt of a written complaint. If the health plan 69.2company cannot make a decision within 30 days due to circumstances outside the control 69.3of the health plan company, the health plan company may take up to 14 additional days to 69.4notify the complainant of its decision. If the health plan company takes any additional 69.5days beyond the initial 30-day period to make its decision, it must inform the complainant, 69.6in advance, of the extension and the reasons for the extension. 69.7(b) new text begin For group health plans, new text end if the decision is partially or wholly adverse to the 69.8complainant, the notification must inform the complainant of the right to appeal the 69.9decision to the health plan company's internal appeal process described in section 62Q.70 69.10and the procedure for initiating an appeal. 69.11 new text begin (c) For individual health plans, if the decision is partially or wholly adverse to new text end 69.12 new text begin the complainant, the notification must inform the complainant of the right to submit the new text end 69.13 new text begin complaint decision to the external review process described in section 62Q.73 and the new text end 69.14 new text begin procedure for initiating the external review process. Notwithstanding the provisions in new text end 69.15 new text begin this subdivision, a health plan company offering individual coverage may instead follow new text end 69.16 new text begin the process for group health plans outlined in paragraph (b). new text end 69.17(c) new text begin (d) new text end The notification must also inform the complainant of the right to submit the 69.18complaint at any time to either the commissioner of health or commerce for investigation 69.19and the toll-free telephone number of the appropriate commissioner. 69.20 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 69.21    Sec. 83. Minnesota Statutes 2012, section 62Q.70, subdivision 1, is amended to read: 69.22    Subdivision 1. Establishment. (a) Each health plan company shall establish an 69.23internal appeal process for reviewing a health plan company's decision regarding a 69.24complaint filed in accordance with section 62Q.69. The appeal process must meet the 69.25requirements of this section. new text begin This section applies only to group health plans. However, new text end 69.26 new text begin a health plan company offering individual coverage may, pursuant to section 62Q.69, new text end 69.27 new text begin subdivision 3, paragraph (c), follow the process outlined in this section. new text end 69.28(b) The person or persons with authority to resolve or recommend the resolution of 69.29the internal appeal must not be solely the same person or persons who made the complaint 69.30decision under section 62Q.69. 69.31(c) The internal appeal process must permit the new text begin enrollee to review the information new text end 69.32 new text begin relied upon in the course of the appeal and the new text end receipt of testimony, correspondence, 69.33explanations, or other information from the complainant, staff persons, administrators, 69.34providers, or other persons as deemed necessary by the person or persons investigating or 69.35presiding over the appeal. 70.1 new text begin (d) The enrollee must be allowed to receive continued coverage pending the new text end 70.2 new text begin outcome of the appeals process. new text end 70.3 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 70.4    Sec. 84. Minnesota Statutes 2012, section 62Q.70, subdivision 2, is amended to read: 70.5    Subd. 2. Procedures for filing an appeal. new text begin The health plan company must provide new text end 70.6 new text begin notice to enrollees of its internal appeals process in a culturally and linguistically new text end 70.7 new text begin appropriate manner consistent with the provisions of the Affordable Care Act. new text end If a 70.8complainant notifies the health plan company of the complainant's desire to appeal the 70.9health plan company's decision regarding the complaint through the internal appeal 70.10process, the health plan company must provide the complainant the option for the appeal 70.11to occur either in writing or by hearing. 70.12 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 70.13    Sec. 85. Minnesota Statutes 2012, section 62Q.71, is amended to read: 70.1462Q.71 NOTICE TO ENROLLEES. 70.15Each health plan company shall provide to enrollees a clear and concise description 70.16of its complaint resolution procedure, if applicable under section 62Q.68, subdivision 1, 70.17and the procedure used for utilization review as defined under chapter 62M as part of 70.18the member handbook, subscriber contract, or certificate of coverage. If the health plan 70.19company does not issue a member handbook, the health plan company may provide 70.20the description in another written document. The description must specifically inform 70.21enrollees: 70.22(1) how to submit a complaint to the health plan company; 70.23(2) if the health plan includes utilization review requirements, how to notify the 70.24utilization review organization in a timely manner and how to obtain certification for 70.25health care services; 70.26(3) how to request an appeal either through the procedures described in sections 70.27 and new text begin section new text end 62Q.70 new text begin , if applicable, new text end or through the procedures described in chapter 70.2862M; 70.29(4) of the right to file a complaint with either the commissioner of health or 70.30commerce at any time during the complaint and appeal process; 70.31(5) of the toll-free telephone number of the appropriate commissioner; and 70.32(6) of the right new text begin , for individual and group coverage, new text end to obtain an external review 70.33under section 62Q.73 and a description of when and how that right may be exercised. new text begin , new text end 71.1 new text begin including that under most circumstances an enrollee must exhaust the internal complaint new text end 71.2 new text begin or appeal process prior to external review. However, an enrollee may proceed to external new text end 71.3 new text begin review without exhausting the internal complaint or appeal process under the following new text end 71.4 new text begin circumstances: new text end 71.5 new text begin (i) the health plan company waives the exhaustion requirement; new text end 71.6 new text begin (ii) the health plan company is considered to have waived the exhaustion requirement new text end 71.7 new text begin by failing to substantially comply with any requirements including, but not limited to, new text end 71.8 new text begin time limits for internal complaints or appeals; or new text end 71.9 new text begin (iii) the enrollee has applied for an expedited external review at the same time the new text end 71.10 new text begin enrollee qualifies for and has applied for an expedited internal review under chapter 62M. new text end 71.11 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 71.12    Sec. 86. Minnesota Statutes 2012, section 62Q.73, is amended to read: 71.1362Q.73 EXTERNAL REVIEW OF ADVERSE DETERMINATIONS. 71.14    Subdivision 1. Definition. For purposes of this section, "adverse determination" 71.15means: 71.16(1) new text begin for individual health plans, a complaint decision relating to a health care service new text end 71.17 new text begin or claim that is partially or wholly adverse to the complainant; new text end 71.18 new text begin (2) an individual health plan that is grandfathered plan coverage may instead apply new text end 71.19 new text begin the definition of adverse determination for group coverage in clause (3); new text end 71.20 new text begin (3) for group health plans, new text end a complaint decision relating to a health care service or 71.21claim that has been appealed in accordance with section 62Q.70 and the appeal decision is 71.22partially or wholly adverse to the complainant; 71.23(2) new text begin (4) new text end any initial determination not to certify that has been appealed in accordance 71.24with section 62M.06 and the appeal did not reverse the initial determination not to certify; or 71.25(3) new text begin (5) new text end a decision relating to a health care service made by a health plan company 71.26licensed under chapter 60A that denies the service on the basis that the service was not 71.27medically necessary. new text begin ; or new text end 71.28 new text begin (6) the enrollee has met the requirements of subdivision 6, paragraph (e). new text end 71.29An adverse determination does not include complaints relating to fraudulent marketing 71.30practices or agent misrepresentation. 71.31    Subd. 2. Exception. (a) This section does not apply to governmental programs 71.32except as permitted under paragraph (b). For purposes of this subdivision, "governmental 71.33programs" means the prepaid medical assistance program, the MinnesotaCare program, 72.1the prepaid general assistance medical care program, the demonstration project for people 72.2with disabilities, and the federal Medicare program. 72.3(b) In the course of a recipient's appeal of a medical determination to the 72.4commissioner of human services under section 256.045, the recipient may request an 72.5expert medical opinion be arranged by the external review entity under contract to provide 72.6independent external reviews under this section. If such a request is made, the cost of the 72.7review shall be paid by the commissioner of human services. Any medical opinion obtained 72.8under this paragraph shall only be used by a state human services referee as evidence in 72.9the recipient's appeal to the commissioner of human services under section 256.045. 72.10(c) Nothing in this subdivision shall be construed to limit or restrict the appeal rights 72.11provided in section 256.045 for governmental program recipients. 72.12    Subd. 3. Right to external review. (a) Any enrollee or anyone acting on behalf 72.13of an enrollee who has received an adverse determination may submit a written request 72.14for an external review of the adverse determination, if applicable under section 62Q.68, 72.15subdivision 1 , or 62M.06, to the commissioner of health if the request involves a health 72.16plan company regulated by that commissioner or to the commissioner of commerce if the 72.17request involves a health plan company regulated by that commissioner. Notification of 72.18the enrollee's right to external review must accompany the denial issued by the insurer. 72.19The written request must be accompanied by a filing fee of $25. The fee may be waived 72.20by the commissioner of health or commerce in cases of financial hardship new text begin and must be new text end 72.21 new text begin refunded if the adverse determination is completely reversed. No enrollee may be subject new text end 72.22 new text begin to filing fees totaling more than $75 during a plan year for group coverage or policy year new text end 72.23 new text begin for individual coverage new text end . 72.24(b) Nothing in this section requires the commissioner of health or commerce to 72.25independently investigate an adverse determination referred for independent external 72.26review. 72.27(c) If an enrollee requests an external review, the health plan company must 72.28participate in the external review. The cost of the external review in excess of the filing 72.29fee described in paragraph (a) shall be borne by the health plan company. 72.30 new text begin (d) The enrollee must request external review within six months from the date of new text end 72.31 new text begin the adverse determination. new text end 72.32    Subd. 4. Contract. Pursuant to a request for proposal, the commissioner of 72.33administration, in consultation with the commissioners of health and commerce, shall 72.34contract with an organization new text begin at least three organizations new text end or business entity new text begin entities new text end to 72.35provide independent external reviews of all adverse determinations submitted for external 73.1review. The contract shall ensure that the fees for services rendered in connection with the 73.2reviews be new text begin are new text end reasonable. 73.3    Subd. 5. Criteria. (a) The request for proposal must require that the entity 73.4demonstrate: 73.5(1) no conflicts of interest in that it is not owned, a subsidiary of, or affiliated 73.6with a health plan company or new text begin , new text end utilization review organization new text begin , or a trade organization new text end 73.7 new text begin of health care providers new text end ; 73.8(2) an expertise in dispute resolution; 73.9(3) an expertise in health-related law; 73.10(4) an ability to conduct reviews using a variety of alternative dispute resolution 73.11procedures depending upon the nature of the dispute; 73.12(5) an ability to new text begin maintain written records, for at least three years, regarding reviews new text end 73.13 new text begin conducted and new text end provide data to the commissioners of health and commerce new text begin upon request new text end on 73.14reviews conducted; and 73.15(6) an ability to ensure confidentiality of medical records and other enrollee 73.16information. new text begin ; new text end 73.17 new text begin (7) accreditation by nationally recognized private accrediting organization; and new text end 73.18 new text begin (8) the ability to provide an expedited external review process. new text end 73.19(b) The commissioner of administration shall take into consideration, in awarding 73.20the contract according to subdivision 4, any national accreditation standards that pertain to 73.21an external review entity. 73.22    Subd. 6. Process. (a) Upon receiving a request for an external review, the 73.23 new text begin commissioner shall assign an external review entity on a random basis. The assigned new text end 73.24 external review entity must provide immediate notice of the review to the enrollee and to 73.25the health plan company. Within ten business days of receiving notice of the review, the 73.26health plan company and the enrollee must provide the new text begin assigned new text end external review entity 73.27with any information that they wish to be considered. Each party shall be provided an 73.28opportunity to present its version of the facts and arguments. new text begin The assigned external review new text end 73.29 new text begin entity must furnish to the health plan company any additional information submitted by new text end 73.30 new text begin the enrollee within one business day of receipt. new text end An enrollee may be assisted or represented 73.31by a person of the enrollee's choice. 73.32(b) As part of the external review process, any aspect of an external review involving 73.33a medical determination must be performed by a health care professional with expertise in 73.34the medical issue being reviewed. 73.35(c) An external review shall be made as soon as practical but in no case later than 40 73.36 new text begin 45 new text end days after receiving the request for an external review and must promptly send written 74.1notice of the decision and the reasons for it to the enrollee, the health plan company, and 74.2the commissioner who is responsible for regulating the health plan company. 74.3 new text begin (d) The external review entity and the clinical reviewer assigned must not have a new text end 74.4 new text begin material professional, familial, or financial conflict of interest with: new text end 74.5 new text begin (1) the health plan company that is the subject of the external review; new text end 74.6 new text begin (2) the enrollee, or any parties related to the enrollee, whose treatment is the subject new text end 74.7 new text begin of the external review; new text end 74.8 new text begin (3) any officer, director, or management employee of the health plan company; new text end 74.9 new text begin (4) a plan administrator, plan fiduciaries, or plan employees; new text end 74.10 new text begin (5) the health care provider, the health care provider's group, or practice association new text end 74.11 new text begin recommending treatment that is the subject of the external review; new text end 74.12 new text begin (6) the facility at which the recommended treatment would be provided; or new text end 74.13 new text begin (7) the developer or manufacturer of the principal drug, device, procedure, or other new text end 74.14 new text begin therapy being recommended. new text end 74.15 new text begin (e)(1) An expedited external review must be provided if the enrollee requests it new text end 74.16 new text begin after receiving: new text end 74.17 new text begin (i) an adverse determination that involves a medical condition for which the time new text end 74.18 new text begin frame for completion of an expedited internal appeal would seriously jeopardize the life new text end 74.19 new text begin or health of the enrollee or would jeopardize the enrollee's ability to regain maximum new text end 74.20 new text begin function and the enrollee has simultaneously requested an expedited internal appeal; new text end 74.21 new text begin (ii) an adverse determination that concerns an admission, availability of care, new text end 74.22 new text begin continued stay, or health care service for which the enrollee received emergency services new text end 74.23 new text begin but has not been discharged from a facility; or new text end 74.24 new text begin (iii) an adverse determination that involves a medical condition for which the new text end 74.25 new text begin standard external review time would seriously jeopardize the life or health of the enrollee new text end 74.26 new text begin or jeopardize the enrollee's ability to regain maximum function. new text end 74.27 new text begin (2) The external review entity must make its expedited determination to uphold or new text end 74.28 new text begin reverse the adverse determination as expeditiously as possible but within no more than 72 new text end 74.29 new text begin hours after the receipt of the request for expedited review and notify the enrollee and the new text end 74.30 new text begin health plan company of the determination. new text end 74.31 new text begin (3) If the external review entity's notification is not in writing, the external review new text end 74.32 new text begin entity must provide written confirmation of the determination within 48 hours of the new text end 74.33 new text begin notification. new text end 74.34    Subd. 7. Standards of review. (a) For an external review of any issue in an adverse 74.35determination that does not require a medical necessity determination, the external review 75.1must be based on whether the adverse determination was in compliance with the enrollee's 75.2health benefit plan. 75.3(b) For an external review of any issue in an adverse determination by a health plan 75.4company licensed under chapter 62D that requires a medical necessity determination, the 75.5external review must determine whether the adverse determination was consistent with the 75.6definition of medically necessary care in Minnesota Rules, part 4685.0100, subpart 9b. 75.7(c) For an external review of any issue in an adverse determination by a health plan 75.8company, other than a health plan company licensed under chapter 62D, that requires a 75.9medical necessity determination, the external review must determine whether the adverse 75.10determination was consistent with the definition of medically necessary care in section 75.1162Q.53, subdivision 2 . 75.12 new text begin (d) For an external review of an adverse determination involving experimental new text end 75.13 new text begin or investigational treatment, the external review entity must base its decision on all new text end 75.14 new text begin documents submitted by the health plan company and enrollee, including medical new text end 75.15 new text begin records, the attending physician or health care professional's recommendation, consulting new text end 75.16 new text begin reports from health care professionals, the terms of coverage, federal Food and Drug new text end 75.17 new text begin Administration approval, and medical or scientific evidence or evidence-based standards. new text end 75.18    Subd. 8. Effects of external review. A decision rendered under this section shall 75.19be nonbinding on the enrollee and binding on the health plan company. The health plan 75.20company may seek judicial review of the decision on the grounds that the decision was 75.21arbitrary and capricious or involved an abuse of discretion. 75.22    Subd. 9. Immunity from civil liability. A person who participates in an external 75.23review by investigating, reviewing materials, providing technical expertise, or rendering a 75.24decision shall not be civilly liable for any action that is taken in good faith, that is within 75.25the scope of the person's duties, and that does not constitute willful or reckless misconduct. 75.26    Subd. 10. Data reporting. The commissioners shall make available to the public, 75.27upon request, summary data on the decisions rendered under this section, including the 75.28number of reviews heard and decided and the final outcomes. Any data released to the 75.29public must not individually identify the enrollee initiating the request for external review. 75.30 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 75.31    Sec. 87. Minnesota Statutes 2012, section 62Q.75, subdivision 1, is amended to read: 75.32    Subdivision 1. Definitions. (a) For purposes of this section, the following terms 75.33have the meanings given to them. 75.34(b) "Clean claim" means a claim that has no defect or impropriety, including any lack 75.35of any required substantiating documentation, including, but not limited to, coordination 76.1of benefits information, or particular circumstance requiring special treatment that 76.2prevents timely payment from being made on a claim under this section. new text begin A special new text end 76.3 new text begin circumstance includes, but is not limited to, a claim held pending payment of an overdue new text end 76.4 new text begin premium for the time period during which the expense was incurred as allowed by the new text end 76.5 new text begin Affordable Care Act. new text end Nothing in this section alters an enrollee's obligation to disclose 76.6information as required by law. 76.7(c) "Third-party administrator" means a third-party administrator or other entity 76.8subject to section 60A.23, subdivision 8, and Minnesota Rules, chapter 2767. 76.9 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 76.10    Sec. 88. Minnesota Statutes 2012, section 62Q.80, subdivision 2, is amended to read: 76.11    Subd. 2. Definitions. For purposes of this section, the following definitions apply: 76.12(a) "Community-based" means located in or primarily relating to the community, 76.13as determined by the board of a community-based health initiative that is served by the 76.14community-based health care coverage program. 76.15(b) "Community-based health care coverage program" or "program" means a 76.16program administered by a community-based health initiative that provides health care 76.17services through provider members of a community-based health network or combination 76.18of networks to eligible individuals and their dependents who are enrolled in the program. 76.19(c) "Community-based health initiative" or "initiative" means a nonprofit corporation 76.20that is governed by a board that has at least 80 percent of its members residing in the 76.21community and includes representatives of the participating network providers and 76.22employers, or a county-based purchasing organization as defined in section 256B.692. 76.23(d) "Community-based health network" means a contract-based network of health 76.24care providers organized by the community-based health initiative to provide or support 76.25the delivery of health care services to enrollees of the community-based health care 76.26coverage program on a risk-sharing or nonrisk-sharing basis. 76.27(e) "Dependent" means an eligible employee's spouse or unmarried child who 76.28is under the age of 19 new text begin 26 new text end years. 76.29 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 76.30    Sec. 89. new text begin [62Q.81] ESSENTIAL HEALTH BENEFIT PACKAGE new text end 76.31 new text begin REQUIREMENTS. new text end 76.32     new text begin Subdivision 1. new text end new text begin Essential health benefits package. new text end new text begin (a) Health plan companies new text end 76.33 new text begin offering individual and small group health plans must include the essential health benefits new text end 77.1 new text begin package required under section 1302(a) of the Affordable Care Act and as described new text end 77.2 new text begin in this subdivision. new text end 77.3     new text begin (b) The essential health benefits package means coverage that: new text end 77.4     new text begin (1) provides essential health benefits as outlined in the Affordable Care Act; new text end 77.5     new text begin (2) limits cost-sharing for such coverage in accordance with the Affordable Care new text end 77.6 new text begin Act, as described in subdivision 2; and new text end 77.7     new text begin (3) subject to subdivision 3, provides bronze, silver, gold, or platinum level of new text end 77.8 new text begin coverage in accordance with the Affordable Care Act. new text end 77.9     new text begin Subd. 2. new text end new text begin Coverage for enrollees under the age of 21. new text end new text begin If a health plan company new text end 77.10 new text begin offers health plans in any level of coverage specified under section 1302(d) of the new text end 77.11 new text begin Affordable Care Act, as described in subdivision 1, paragraph (b), clause (3), the health new text end 77.12 new text begin plan company shall also offer coverage in that level to individuals who have not attained new text end 77.13 new text begin 21 years of age as of the beginning of a policy year. new text end 77.14     new text begin Subd. 3. new text end new text begin Alternative compliance for catastrophic plans. new text end new text begin A health plan company new text end 77.15 new text begin that does not provide an individual or small group health plan in the bronze, silver, gold, new text end 77.16 new text begin or platinum level of coverage, as described in subdivision 1, paragraph (b), clause (3), new text end 77.17 new text begin shall be treated as meeting the requirements of section 1302(d) of the Affordable Care Act new text end 77.18 new text begin with respect to any policy year if the health plan company provides a catastrophic plan new text end 77.19 new text begin that meets the requirements of section 1302(e) of the Affordable Care Act. new text end 77.20     new text begin Subd. 4. new text end new text begin Essential health benefits; definition. new text end new text begin For purposes of this section, new text end 77.21 new text begin "essential health benefits" has the meaning given under section 1302(b) of the Affordable new text end 77.22 new text begin Care Act and includes: new text end 77.23     new text begin (1) ambulatory patient services; new text end 77.24     new text begin (2) emergency services; new text end 77.25     new text begin (3) hospitalization; new text end 77.26     new text begin (4) laboratory services; new text end 77.27     new text begin (5) maternity and newborn care; new text end 77.28     new text begin (6) mental health and substance use disorder services, including behavioral health new text end 77.29 new text begin treatment; new text end 77.30     new text begin (7) pediatric services, including oral and vision care; new text end 77.31     new text begin (8) prescription drugs; new text end 77.32     new text begin (9) preventive and wellness services and chronic disease management; new text end 77.33     new text begin (10) rehabilitative and habilitative services and devices; and new text end 77.34     new text begin (11) additional essential health benefits included in the EHB-benchmark plan, as new text end 77.35 new text begin defined under the Affordable Care Act. new text end 78.1     new text begin Subd. 5. new text end new text begin Exception. new text end new text begin This section does not apply to a dental plan described in new text end 78.2 new text begin section 1311(d)(2)(B)(ii) of the Affordable Care Act. new text end 78.3 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 78.4    Sec. 90. new text begin [62Q.82] BENEFITS AND COVERAGE EXPLANATION. new text end 78.5     new text begin Subdivision 1. new text end new text begin Summary. new text end new text begin Health plan companies offering health plans shall provide new text end 78.6 new text begin a summary of benefits and coverage explanation as required by the Affordable Care Act to: new text end 78.7 new text begin (1) an applicant at the time of application; new text end 78.8 new text begin (2) an enrollee prior to the time of enrollment or reenrollment, as applicable; and new text end 78.9 new text begin (3) a policyholder at the time of issuance of the policy. new text end 78.10     new text begin Subd. 2. new text end new text begin Compliance. new text end new text begin A health plan company described in subdivision 1 shall be new text end 78.11 new text begin deemed to have complied with subdivision 1 if the summary of benefits and coverage new text end 78.12 new text begin explanation is provided in paper or electronic form as required under the Affordable new text end 78.13 new text begin Care Act. new text end 78.14     new text begin Subd. 3. new text end new text begin Notice of modification. new text end new text begin Except in connection with a policy renewal or new text end 78.15 new text begin reissuance, if a health plan company makes any material modifications in any of the new text end 78.16 new text begin terms of the coverage, as defined for purposes of section 102 of the federal Employee new text end 78.17 new text begin Retirement Income Security Act of 1974, as amended, that is not reflected in the most new text end 78.18 new text begin recently provided summary of benefits and coverage explanation, the health plan company new text end 78.19 new text begin shall provide notice of the modification to enrollees not later than 60 days prior to the date new text end 78.20 new text begin on which the modification will become effective. new text end 78.21 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 78.22    Sec. 91. Minnesota Statutes 2012, section 72A.20, subdivision 35, is amended to read: 78.23    Subd. 35. Determination of health plan policy limits. Any health plan new text begin under new text end 78.24 new text begin section 62A.011, subdivision 3, new text end that includes a specific policy limit within its insurance 78.25policy, certificate, or subscriber agreement shall calculate the policy limit by using the 78.26amount actually paid on behalf of the insured, subscriber, or dependents for services 78.27covered under the policy, subscriber agreement, or certificate unless the amount paid is 78.28greater than the billed charge. new text begin This provision does not permit the application of a specific new text end 78.29 new text begin policy limit within a health plan where the limit is prohibited under the Affordable Care new text end 78.30 new text begin Act as defined in section 62A.011, subdivision 1a. new text end 78.31 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 79.1    Sec. 92. Minnesota Statutes 2012, section 145.414, is amended to read: 79.2145.414 ABORTION NOT MANDATORY. 79.3(a) No person and no hospital or institution shall be coerced, held liable or 79.4discriminated against in any manner because of a refusal to perform, accommodate, assist 79.5or submit to an abortion for any reason. 79.6(b) It is the policy of the state of Minnesota that no health plan company as defined 79.7under section 62Q.01, subdivision 4, or health care cooperative as defined under section 79.862R.04, subdivision 2 , shall be required to provide or provide coverage for an abortion. 79.9No provision of this chapter; of chapter 62A, 62C, 62D, 62H, 62L, 62M, 62N, 62R, 79.10 new text begin 62V, new text end 64B, or of any other chapter; of Minnesota Rules; or of Laws 1995, chapter 234, 79.11shall be construed as requiring a health plan company as defined under section 62Q.01, 79.12subdivision 4 , or a health care cooperative as defined under section 62R.04, subdivision 2, 79.13to provide or provide coverage for an abortion. 79.14(c) This section supersedes any provision of Laws 1995, chapter 234, or any act 79.15enacted prior to enactment of Laws 1995, chapter 234, that in any way limits or is 79.16inconsistent with this section. No provision of any act enacted subsequent to Laws 1995, 79.17chapter 234 shall be construed as in any way limiting or being inconsistent with this 79.18section, unless the act amends this section or expressly provides that it is intended to 79.19limit or be inconsistent with this section. 79.20    Sec. 93. Minnesota Statutes 2012, section 471.61, subdivision 1a, is amended to read: 79.21    Subd. 1a. Dependents. Notwithstanding the provisions of Minnesota Statutes 1969, 79.22section 471.61, as amended by Laws 1971, chapter 451, section 1, the word "dependents" as 79.23used therein shall mean spouse and minor unmarried children under the age of 18 new text begin 26 new text end years 79.24and dependent students under the age of 25 years actually dependent upon the employee. 79.25 new text begin EFFECTIVE DATE. new text end new text begin This section is effective the day following final enactment. new text end 79.26    Sec. 94. new text begin REPEALER. new text end 79.27 new text begin (a) new text end new text begin Minnesota Statutes 2012, section 62E.02, subdivision 7, new text end new text begin is repealed effective the new text end 79.28 new text begin day following final enactment. new text end 79.29 new text begin (b) new text end new text begin Minnesota Statutes 2012, sections 62A.615; 62A.65, subdivision 6; 62E.16; new text end 79.30 new text begin 62E.20; 62L.02, subdivisions 4, 18, 19, 23, and 24; 62L.05, subdivisions 1, 2, 3, 4, 4a, new text end 79.31 new text begin 5, 6, 7, 11, 12, and 13; 62L.081; 62L.10, subdivision 5; and 62Q.37, subdivision 5, new text end new text begin are new text end 79.32 new text begin repealed effective January 1, 2014. new text end 80.1ARTICLE 2 80.2MARKET RULES FOR AFFORDABLE CARE ACT 80.3    Section 1. Minnesota Statutes 2012, section 62D.124, subdivision 4, is amended to read: 80.4    Subd. 4. Application. (a) Subdivisions 1 and 2 do not apply if an enrollee is referred 80.5to a referral center for health care services. 80.6(b) Subdivision 1 does not apply: 80.7(1) if an enrollee has chosen a health plan with full knowledge that the health plan 80.8has no participating providers within 30 miles or 30 minutes of the enrollee's place of 80.9residence; or 80.10(2) to service areas approved before May 24, 1993. 80.11 new text begin (c) Beginning for coverage effective on or after January 1, 2015, subdivisions 1 to 4 new text end 80.12 new text begin shall only apply to individual or small group health plans that are grandfathered plans, as new text end 80.13 new text begin defined under section 62A.011, subdivision 1c. new text end 80.14    Sec. 2. new text begin [62K.01] TITLE. new text end 80.15 new text begin This chapter may be cited as the "Minnesota Health Plan Market Rules." new text end 80.16    Sec. 3. new text begin [62K.02] PURPOSE AND SCOPE. new text end 80.17     new text begin Subdivision 1. new text end new text begin Purpose. new text end new text begin The market rules set forth in this chapter serve to clarify new text end 80.18 new text begin and provide guidance on the application of state law and certain requirements of the new text end 80.19 new text begin Affordable Care Act on all health carriers offering health plans in Minnesota, whether new text end 80.20 new text begin or not through the Minnesota Insurance Marketplace, to ensure fair competition for all new text end 80.21 new text begin health carriers in Minnesota, to minimize adverse selection, and to ensure that health new text end 80.22 new text begin plans are offered in a manner that protects consumers and promotes the provision of new text end 80.23 new text begin high-quality affordable health care, and improved health outcomes. This chapter contains new text end 80.24 new text begin the regulatory requirements as specified in section 62V.05, subdivision 5, paragraph (b), new text end 80.25 new text begin and shall fully satisfy the requirements of section 62V.05, subdivision 5, paragraph (b). new text end 80.26     new text begin Subd. 2. new text end new text begin Scope. new text end new text begin (a) This chapter applies only to health plans offered in the new text end 80.27 new text begin individual market or the small group market. new text end 80.28 new text begin (b) This chapter applies to health carriers with respect to individual health plans and new text end 80.29 new text begin small group health plans, unless otherwise specified. new text end 80.30 new text begin (c) If a health carrier issues or renews individual or small group health plans in new text end 80.31 new text begin other states, this chapter applies only to health plans issued or renewed in this state to a new text end 80.32 new text begin Minnesota resident, or to cover a resident of the state, or issued or renewed to a small new text end 80.33 new text begin employer that is actively engaged in business in this state, unless otherwise specified. new text end 81.1 new text begin (d) This chapter does not apply to short-term coverage as defined in section 62A.65, new text end 81.2 new text begin subdivision 7, or grandfathered plan coverage as defined in section 62A.011, subdivision new text end 81.3 new text begin 1b. new text end 81.4 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for health plans that are offered, sold, new text end 81.5 new text begin issued or renewed on or after January 1, 2014. new text end 81.6    Sec. 4. new text begin [62K.03] DEFINITIONS. new text end 81.7     new text begin Subdivision 1. new text end new text begin Applicability. new text end new text begin For purposes of this chapter, the terms defined in this new text end 81.8 new text begin section have the meanings given. new text end 81.9     new text begin Subd. 2. new text end new text begin Affordable Care Act. new text end new text begin "Affordable Care Act" means the federal Patient new text end 81.10 new text begin Protection and Affordable Care Act, Public Law 111-148, as amended, including the new text end 81.11 new text begin federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and new text end 81.12 new text begin any amendments, and any federal guidance or regulations issued under these acts. new text end 81.13     new text begin Subd. 3. new text end new text begin Dental plan. new text end new text begin "Dental plan" means a dental plan as defined in section new text end 81.14 new text begin 62Q.76, subdivision 3. new text end 81.15     new text begin Subd. 4. new text end new text begin Enrollee. new text end new text begin "Enrollee" means a natural person covered by a health plan and new text end 81.16 new text begin includes an insured policyholder, subscriber, contract holder, member, covered person, new text end 81.17 new text begin or certificate holder. new text end 81.18     new text begin Subd. 5. new text end new text begin Health carrier. new text end new text begin "Health carrier" means a health carrier as defined in new text end 81.19 new text begin section 62A.011, subdivision 2. new text end 81.20     new text begin Subd. 6. new text end new text begin Health plan. new text end new text begin "Health plan" means a health plan as defined in section new text end 81.21 new text begin 62A.011, subdivision 3. new text end 81.22     new text begin Subd. 7. new text end new text begin Individual health plan. new text end new text begin "Individual health plan" means an individual new text end 81.23 new text begin health plan as defined in Minnesota Statutes, section 62A.011, subdivision 4. new text end 81.24     new text begin Subd. 8. new text end new text begin Limited-scope pediatric dental plan. new text end new text begin "Limited-scope pediatric dental new text end 81.25 new text begin plan" means a dental plan meeting the requirements of section 9832(c)(2)(A) of the new text end 81.26 new text begin Internal Revenue Code of 1986, as amended, that provides only pediatric dental benefits new text end 81.27 new text begin meeting the requirements of the Affordable Care Act and is offered by a health carrier. A new text end 81.28 new text begin limited-scope pediatric dental plan includes a dental plan that is offered separately or in new text end 81.29 new text begin conjunction with an individual or small group health plan to individuals who have not new text end 81.30 new text begin attained the age of 19 years as of the beginning of the policy year or to a family. new text end 81.31     new text begin Subd. 9. new text end new text begin Minnesota Insurance Marketplace. new text end new text begin "Minnesota Insurance Marketplace" new text end 81.32 new text begin means the Minnesota Insurance Marketplace as defined in section 62V.02. new text end 81.33     new text begin Subd. 10. new text end new text begin Preferred provider organization. new text end new text begin "Preferred provider organization" new text end 81.34 new text begin means a health plan that provides discounts to enrollees or subscribers for services they new text end 81.35 new text begin receive from certain health care providers. new text end 82.1     new text begin Subd. 11. new text end new text begin Qualified health plan. new text end new text begin "Qualified health plan" means a health plan new text end 82.2 new text begin that meets the definition in the Affordable Care Act and has been certified by the board new text end 82.3 new text begin of the Minnesota Insurance Marketplace in accordance with chapter 62V to be offered new text end 82.4 new text begin through the Minnesota Insurance Marketplace. new text end 82.5     new text begin Subd. 12. new text end new text begin Small group health plan. new text end new text begin "Small group health plan" means a health plan new text end 82.6 new text begin issued by a health carrier to a small employer as defined in section 62L.02, subdivision 26. new text end 82.7 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for health plans that are offered, sold, new text end 82.8 new text begin issued, or renewed on or after January 1, 2014. new text end 82.9    Sec. 5. new text begin [62K.04] MARKET RULES; VIOLATION. new text end 82.10     new text begin Subdivision 1. new text end new text begin Compliance. new text end new text begin (a) A health carrier issuing an individual health plan to new text end 82.11 new text begin a Minnesota resident or a small group health plan to provide coverage to a small employer new text end 82.12 new text begin that is actively engaged in business in Minnesota shall meet all of the requirements set new text end 82.13 new text begin forth in this chapter. The failure to meet any of the requirements under this chapter new text end 82.14 new text begin constitutes a violation of section 72A.20. new text end 82.15 new text begin (b) The requirements of this chapter do not apply to short-term coverage as defined new text end 82.16 new text begin in section 62A.65, subdivision 7, or grandfathered plan coverage as defined in section new text end 82.17 new text begin 62A.011, subdivision 1c. new text end 82.18     new text begin Subd. 2. new text end new text begin Penalties. new text end new text begin In addition to any other penalties provided by the laws of this new text end 82.19 new text begin state or by federal law, a health carrier or any other person found to have violated any new text end 82.20 new text begin requirement of this chapter may be subject to the administrative procedures, enforcement new text end 82.21 new text begin actions, and penalties provided under section 45.027 and chapters 62D and 72A. new text end 82.22 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for health plans that are offered, sold, new text end 82.23 new text begin issued, or renewed on or after January 1, 2014. new text end 82.24    Sec. 6. new text begin [62K.05] FEDERAL ACT; COMPLIANCE REQUIRED. new text end 82.25 new text begin A health carrier shall comply with all provisions of the Affordable Care Act to new text end 82.26 new text begin the extent that it imposes a requirement that applies in this state. Compliance with any new text end 82.27 new text begin provision of the Affordable Care Act is required as of the effective date established for new text end 82.28 new text begin that provision in the federal act, except as otherwise specifically stated earlier in state law. new text end 82.29 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for health plans that are offered, sold, new text end 82.30 new text begin issued, or renewed on or after January 1, 2014. new text end 82.31    Sec. 7. new text begin [62K.06] METAL LEVEL MANDATORY OFFERINGS. new text end 83.1     new text begin Subdivision 1. new text end new text begin Identification. new text end new text begin A health carrier that offers individual or small group new text end 83.2 new text begin health plans in Minnesota must provide documentation to the commissioner of commerce new text end 83.3 new text begin to justify actuarial value levels as specified in section 1302(d) of the Affordable Care Act new text end 83.4 new text begin for all individual and small group health plans offered inside and outside of the Minnesota new text end 83.5 new text begin Insurance Marketplace. new text end 83.6     new text begin Subd. 2. new text end new text begin Minimum levels. new text end new text begin (a) A health carrier that offers a catastrophic plan or a new text end 83.7 new text begin bronze level health plan within a service area in either the individual or small group new text end 83.8 new text begin market must also offer a silver level and a gold level health plan in that market and new text end 83.9 new text begin within that service area. new text end 83.10 new text begin (b) A health carrier with less than five percent market share in the respective new text end 83.11 new text begin individual or small group market in Minnesota is exempt from paragraph (a), until January new text end 83.12 new text begin 1, 2017, unless the health carrier offers a qualified health plan through the Minnesota new text end 83.13 new text begin Insurance Marketplace. If the health carrier offers a qualified health plan through the new text end 83.14 new text begin Minnesota Insurance Marketplace, the health carrier must comply with paragraph (a). new text end 83.15     new text begin Subd. 3. new text end new text begin Minnesota Insurance Marketplace restriction. new text end new text begin The Minnesota Insurance new text end 83.16 new text begin Marketplace may not, by contract or otherwise, mandate the types of health plans to be new text end 83.17 new text begin offered by a health carrier to individuals or small employers purchasing health plans outside new text end 83.18 new text begin of the Minnesota Insurance Marketplace. Solely for purposes of this subdivision, "health new text end 83.19 new text begin plan" includes coverage that is excluded under section 62A.011, subdivision 3, clause (6). new text end 83.20     new text begin Subd. 4. new text end new text begin Metal level defined. new text end new text begin For purposes of this section, the metal levels and new text end 83.21 new text begin catastrophic plans are defined in section 1302(d) and (e) of the Affordable Care Act. new text end 83.22     new text begin Subd. 5. new text end new text begin Enforcement. new text end new text begin The commissioner of commerce shall enforce this section. new text end 83.23    Sec. 8. new text begin [62K.07] INFORMATION DISCLOSURES. new text end 83.24 new text begin (a) A health carrier offering individual or small group health plans must submit the new text end 83.25 new text begin following information in a format determined by the commissioner of commerce: new text end 83.26 new text begin (1) claims payment policies and practices; new text end 83.27 new text begin (2) periodic financial disclosures; new text end 83.28 new text begin (3) data on enrollment; new text end 83.29 new text begin (4) data on disenrollment; new text end 83.30 new text begin (5) data on the number of claims that are denied; new text end 83.31 new text begin (6) data on rating practices; new text end 83.32 new text begin (7) information on cost-sharing and payments with respect to out-of-network new text end 83.33 new text begin coverage; and new text end 83.34 new text begin (8) other information required by the secretary of the United States Department of new text end 83.35 new text begin Health and Human Services under the Affordable Care Act. new text end 84.1 new text begin (b) A health carrier offering an individual or small group health plan must comply new text end 84.2 new text begin with all information disclosure requirements of all applicable state and federal law, new text end 84.3 new text begin including the Affordable Care Act. new text end 84.4 new text begin (c) Except for qualified health plans sold on the Minnesota Insurance Marketplace, new text end 84.5 new text begin information reported under paragraph (a), clauses (3) and (4), is nonpublic data as defined new text end 84.6 new text begin under section 13.02, subdivision 9. Information reported under paragraph (a), clauses (1) new text end 84.7 new text begin through (8), must be reported by the Minnesota Insurance Marketplace for qualified health new text end 84.8 new text begin plans sold through the Minnesota Insurance Marketplace. new text end 84.9 new text begin (d) The commissioner of commerce shall enforce this section. new text end 84.10    Sec. 9. new text begin [62K.08] MARKETING STANDARDS. new text end 84.11     new text begin Subdivision 1. new text end new text begin Marketing. new text end new text begin (a) A health carrier offering individual or small group new text end 84.12 new text begin health plans must comply with all applicable provisions of the Affordable Care Act, new text end 84.13 new text begin including, but not limited to, the following: new text end 84.14 new text begin (1) compliance with all state laws pertaining to the marketing of individual or small new text end 84.15 new text begin group health plans; and new text end 84.16 new text begin (2) establishing marketing practices and benefit designs that will not have the effect of new text end 84.17 new text begin discouraging the enrollment of individuals with significant health needs in the health plan. new text end 84.18 new text begin (b) No marketing materials may lead consumers to believe that all health care needs new text end 84.19 new text begin will be covered. new text end 84.20     new text begin Subd. 2. new text end new text begin Enforcement. new text end new text begin The commissioner of commerce shall enforce this section. new text end 84.21 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for health plans offered, sold, issued, new text end 84.22 new text begin or renewed on or after January 1, 2014. new text end 84.23    Sec. 10. new text begin [62K.09] ACCREDITATION STANDARDS. new text end 84.24     new text begin Subdivision 1. new text end new text begin Accreditation; general. new text end new text begin (a) A health carrier that offers any new text end 84.25 new text begin individual or small group health plans in Minnesota outside of the Minnesota Insurance new text end 84.26 new text begin Marketplace must be accredited in accordance with this subdivision. A health carrier new text end 84.27 new text begin must obtain accreditation through URAC, the National Committee for Quality Assurance new text end 84.28 new text begin (NCQA), or any entity recognized by the United States Department of Health and Human new text end 84.29 new text begin Services for accreditation of health insurance issuers or health plans by January 1, new text end 84.30 new text begin 2018. Proof of accreditation must be submitted to the commissioner of health in a form new text end 84.31 new text begin prescribed by the commissioner of health. new text end 84.32 new text begin (b) A health carrier that rents a provider network is exempt from this subdivision, new text end 84.33 new text begin unless it is part of a holding company as defined in section 60D.15 that in aggregate exceeds new text end 84.34 new text begin ten percent market share in either the individual or small group market in Minnesota. new text end 85.1     new text begin Subd. 2. new text end new text begin Accreditation; Minnesota Insurance Marketplace. new text end new text begin (a) The Minnesota new text end 85.2 new text begin Insurance Marketplace shall require all health carriers offering a qualified health new text end 85.3 new text begin plan through the Minnesota Insurance Marketplace to obtain the appropriate level of new text end 85.4 new text begin accreditation no later than the third year after the first year the health carrier offers a new text end 85.5 new text begin qualified health plan through the Minnesota Insurance Marketplace. A health carrier new text end 85.6 new text begin must take the first step of the accreditation process during the first year in which it offers new text end 85.7 new text begin a qualified health plan. A health carrier that offers a qualified health plan on January 1, new text end 85.8 new text begin 2014, must obtain accreditation by the end of the 2016 plan year. new text end 85.9 new text begin (b) To the extent a health carrier cannot obtain accreditation due to low volume of new text end 85.10 new text begin enrollees, an exception to this accreditation criterion may be granted by the Minnesota new text end 85.11 new text begin Insurance Marketplace until such time as the health carrier has a sufficient volume of new text end 85.12 new text begin enrollees. new text end 85.13     new text begin Subd. 3. new text end new text begin Oversight. new text end new text begin A health carrier shall comply with a request from the new text end 85.14 new text begin commissioner of health to confirm accreditation or progress toward accreditation. new text end 85.15     new text begin Subd. 4. new text end new text begin Enforcement. new text end new text begin The commissioner of health shall enforce this section. new text end 85.16    Sec. 11. new text begin [62K.10] GEOGRAPHIC ACCESSIBILITY; PROVIDER NETWORK new text end 85.17 new text begin ADEQUACY. new text end 85.18     new text begin Subdivision 1. new text end new text begin Applicability. new text end new text begin (a) This section applies to all health carriers that either new text end 85.19 new text begin require an enrollee to use or that create incentives, including financial incentives, for an new text end 85.20 new text begin enrollee to use, health care providers that are managed, owned, under contract with, or new text end 85.21 new text begin employed by the health carrier. A health carrier that does not manage, own, or contract new text end 85.22 new text begin directly with providers in Minnesota is exempt from this section, unless it is part of a new text end 85.23 new text begin holding company as defined in section 60D.15 that in aggregate exceeds ten percent in new text end 85.24 new text begin either the individual or small group market in Minnesota. new text end 85.25 new text begin (b) Health carriers renting provider networks from other entities must submit the new text end 85.26 new text begin rental agreement or contract to the commissioner of health for approval. In reviewing the new text end 85.27 new text begin agreements or contracts, the commissioner shall review the agreement or contract to new text end 85.28 new text begin ensure that the entity contracting with health care providers accepts responsibility to meet new text end 85.29 new text begin the requirements in this section. new text end 85.30     new text begin Subd. 2. new text end new text begin Primary care; mental health services; general hospital services. new text end new text begin The new text end 85.31 new text begin maximum travel distance or time shall be the lesser of 30 miles or 30 minutes to the new text end 85.32 new text begin nearest provider of each of the following services: primary care services, mental health new text end 85.33 new text begin services, and general hospital services. new text end 85.34     new text begin Subd. 3. new text end new text begin Other health services. new text end new text begin The maximum travel distance or time shall be the new text end 85.35 new text begin lesser of 60 miles or 60 minutes to the nearest provider of specialty physician services, new text end 86.1 new text begin ancillary services, specialized hospital services, and all other health services not listed in new text end 86.2 new text begin subdivision 2. new text end 86.3     new text begin Subd. 4. new text end new text begin Network adequacy. new text end new text begin Each designated provider network must include a new text end 86.4 new text begin sufficient number and type of providers, including providers that specialize in mental new text end 86.5 new text begin health and substance use disorder services, to ensure that covered services are available new text end 86.6 new text begin to all enrollees without unreasonable delay. In determining network adequacy, the new text end 86.7 new text begin commissioner of health shall consider availability of services, including the following: new text end 86.8 new text begin (1) primary care physician services are available and accessible 24 hours per day, new text end 86.9 new text begin seven days per week, within the network area; new text end 86.10 new text begin (2) a sufficient number of primary care physicians have hospital admitting privileges new text end 86.11 new text begin at one or more participating hospitals within the network area so that necessary admissions new text end 86.12 new text begin are made on a timely basis consistent with generally accepted practice parameters; new text end 86.13 new text begin (3) specialty physician service is available through the network or contract new text end 86.14 new text begin arrangement; new text end 86.15 new text begin (4) mental health and substance use disorder treatment providers are available and new text end 86.16 new text begin accessible through the network or contract arrangement; new text end 86.17 new text begin (5) to the extent that primary care services are provided through primary care new text end 86.18 new text begin providers other than physicians, and to the extent permitted under applicable scope of new text end 86.19 new text begin practice in state law for a given provider, these services shall be available and accessible; new text end 86.20 new text begin and new text end 86.21 new text begin (6) the network has available, either directly or through arrangements, appropriate new text end 86.22 new text begin and sufficient personnel, physical resources, and equipment to meet the projected needs of new text end 86.23 new text begin enrollees for covered health care services. new text end 86.24     new text begin Subd. 5. new text end new text begin Waiver. new text end new text begin A health carrier or preferred provider organization may apply to new text end 86.25 new text begin the commissioner of health for a waiver of the requirements in subdivision 2 or 3 if it is new text end 86.26 new text begin unable to meet the statutory requirements. A waiver application must be submitted on a new text end 86.27 new text begin form provided by the commissioner and must: new text end 86.28 new text begin (1) demonstrate with specific data that the requirement of subdivision 2 or 3 is not new text end 86.29 new text begin feasible in a particular service area or part of a service area; and new text end 86.30 new text begin (2) include information as to the steps that were and will be taken to address the new text end 86.31 new text begin network inadequacy. new text end 86.32 new text begin The waiver shall automatically expire after four years. If a renewal of the waiver new text end 86.33 new text begin is sought, the commissioner of health shall take into consideration steps that have been new text end 86.34 new text begin taken to address network adequacy. new text end 86.35     new text begin Subd. 6. new text end new text begin Referral centers. new text end new text begin Subdivisions 2 and 3 shall not apply if an enrollee new text end 86.36 new text begin is referred to a referral center for health care services. A referral center is a medical new text end 87.1 new text begin facility that provides highly specialized medical care, including but not limited to organ new text end 87.2 new text begin transplants. A health carrier or preferred provider organization may consider the volume new text end 87.3 new text begin of services provided annually, case mix, and severity adjusted mortality and morbidity new text end 87.4 new text begin rates in designating a referral center. new text end 87.5     new text begin Subd. 7. new text end new text begin Essential community providers. new text end new text begin Each health carrier must comply with new text end 87.6 new text begin section 62Q.19. new text end 87.7     new text begin Subd. 8. new text end new text begin Enforcement. new text end new text begin The commissioner of health shall enforce this section. new text end 87.8    Sec. 12. new text begin [62K.11] BALANCE BILLING PROHIBITED. new text end 87.9 new text begin (a) A network provider is prohibited from billing an enrollee for any amount in new text end 87.10 new text begin excess of the allowable amount the health carrier has contracted for with the provider new text end 87.11 new text begin as total payment for the health care service. A network provider is permitted to bill an new text end 87.12 new text begin enrollee the approved co-payment, deductible, or coinsurance. new text end 87.13 new text begin (b) A network provider is permitted to bill an enrollee for services not covered by new text end 87.14 new text begin the enrollee's health plan as long as the enrollee agrees in writing in advance before the new text end 87.15 new text begin service is performed to pay for the noncovered service. new text end 87.16 new text begin EFFECTIVE DATE. new text end new text begin This section is effective January 1, 2014. new text end 87.17    Sec. 13. new text begin [62K.12] QUALITY ASSURANCE AND IMPROVEMENT. new text end 87.18     new text begin Subdivision 1. new text end new text begin General. new text end new text begin (a) All health carriers offering an individual health plan or new text end 87.19 new text begin small group health plan must have a written internal quality assurance and improvement new text end 87.20 new text begin program that, at a minimum: new text end 87.21 new text begin (1) provides for ongoing evaluation of the quality of health care provided to its new text end 87.22 new text begin enrollees; new text end 87.23 new text begin (2) periodically reports the evaluation of the quality of health care to the health new text end 87.24 new text begin carrier's governing body; new text end 87.25 new text begin (3) follows policies and procedures for the selection and credentialing of network new text end 87.26 new text begin providers that is consistent with community standards; new text end 87.27 new text begin (4) conducts focused studies directed at problems, potential problems, or areas new text end 87.28 new text begin with potential for improvements in care; new text end 87.29 new text begin (5) conducts enrollee satisfaction surveys and monitors oral and written complaints new text end 87.30 new text begin submitted by enrollees or members; and new text end 87.31 new text begin (6) collects and reports Health Effectiveness Data and Information Set (HEDIS) new text end 87.32 new text begin measures and conducts other quality assessment and improvement activities as directed new text end 87.33 new text begin by the commissioner of health. new text end 88.1     new text begin (b) The commissioner of health shall submit a report to the chairs and ranking new text end 88.2 new text begin minority members of senate and house of representatives committees with primary new text end 88.3 new text begin jurisdiction over commerce and health policy by February 15, 2015, with recommendations new text end 88.4 new text begin for specific quality assurance and improvement standards for all Minnesota health carriers. new text end 88.5 new text begin The recommended standards must not require duplicative data gathering, analysis, or new text end 88.6 new text begin reporting by health carriers. new text end 88.7     new text begin Subd. 2. new text end new text begin Exemption. new text end new text begin A health carrier that rents a provider network is exempt from new text end 88.8 new text begin this section, unless it is part of a holding company as defined in section 60D.15 that in new text end 88.9 new text begin aggregate exceeds ten percent market share in either the individual or small group market new text end 88.10 new text begin in Minnesota. new text end 88.11     new text begin Subd. 3. new text end new text begin Waiver. new text end new text begin A health carrier that has obtained accreditation through the URAC new text end 88.12 new text begin for network management; quality improvement; credentialing; member protection; and new text end 88.13 new text begin utilization management, or has achieved an excellent or commendable level ranking new text end 88.14 new text begin from the National Committee for Quality Assurance (NCQA), shall be deemed to meet new text end 88.15 new text begin the requirements of subdivision 1. Proof of accreditation must be submitted to the new text end 88.16 new text begin commissioner of health in a form prescribed by the commissioner. The commissioner may new text end 88.17 new text begin adopt rules to recognize similar accreditation standards from any entity recognized by new text end 88.18 new text begin the United States Department of Health and Human Services for accreditation of health new text end 88.19 new text begin insurance issuers or health plans. new text end 88.20     new text begin Subd. 4. new text end new text begin Enforcement. new text end new text begin The commissioner of health shall enforce this section. new text end 88.21    Sec. 14. new text begin [62K.13] SERVICE AREA REQUIREMENTS. new text end 88.22 new text begin (a) Any health carrier that offers an individual or small group health plan, must offer new text end 88.23 new text begin the health plan in a service area that is at least the entire geographic area of a county new text end 88.24 new text begin unless serving a smaller geographic area is necessary, nondiscriminatory, and in the best new text end 88.25 new text begin interest of enrollees. The service area for any individual or small group health plan must new text end 88.26 new text begin be established without regard to racial, ethnic, language, concentrated poverty, or health new text end 88.27 new text begin status-related factors, or other factors that exclude specific high-utilizing, high-cost, or new text end 88.28 new text begin medically underserved populations. new text end 88.29 new text begin (b) If a health carrier that offers an individual or small group health plan requests new text end 88.30 new text begin to serve less than the entire county, the request must be made to the commissioner of new text end 88.31 new text begin health on a form and manner determined by the commissioner and must provide specific new text end 88.32 new text begin data demonstrating that the service area is not discriminatory, is necessary, and is in the new text end 88.33 new text begin best interest of enrollees. new text end 88.34 new text begin (c) The commissioner of health shall enforce this section. new text end 89.1    Sec. 15. new text begin [62K.14] LIMITED-SCOPE PEDIATRIC DENTAL PLANS. new text end 89.2     new text begin (a) Limited-scope pediatric dental plans must be offered to the extent permitted new text end 89.3 new text begin under the Affordable Care Act: (1) on a guaranteed issue and guaranteed renewable basis; new text end 89.4 new text begin (2) with premiums rated on allowable rating factors used for health plans; and (3) without new text end 89.5 new text begin any exclusions or limitations based on preexisting conditions. new text end 89.6     new text begin (b) Notwithstanding paragraph (a), a health carrier may discontinue a limited scope new text end 89.7 new text begin pediatric dental plan at the end of a plan year if the health carrier provides written new text end 89.8 new text begin notice to enrollees before coverage is to be discontinued that the particular plan is being new text end 89.9 new text begin discontinued and the health carrier offers enrollees other dental plan options that are the new text end 89.10 new text begin same or substantially similar to the dental plan being discontinued in terms of premiums, new text end 89.11 new text begin benefits, cost-sharing requirements, and network adequacy. The written notice to enrollees new text end 89.12 new text begin must be provided at least 105 days before the end of the plan year. new text end 89.13 new text begin (c) Limited-scope pediatric dental plans must ensure primary care dental services new text end 89.14 new text begin are available within 60 miles or 60 minutes' travel time. new text end 89.15 new text begin (d) If a stand-alone dental plan as defined under the Affordable Care Act or a new text end 89.16 new text begin limited-scope pediatric dental plan is offered, either separately or in conjunction with new text end 89.17 new text begin a health plan offered to individuals or small employers, the health plan shall not be new text end 89.18 new text begin considered in noncompliance with the requirements of the essential benefit package in the new text end 89.19 new text begin Affordable Care Act because the health plan does not offer coverage of pediatric dental new text end 89.20 new text begin benefits if these benefits are covered through the stand-alone or limited-scope pediatric new text end 89.21 new text begin dental plan, to the extent permitted under the Affordable Care Act. new text end 89.22 new text begin (e) Health carriers offering limited-scope pediatric dental plans must comply with new text end 89.23 new text begin this section and sections 62K.07, 62K.08, 62K.13, and 62K.15. new text end 89.24     new text begin (f) The commissioner of commerce shall enforce paragraphs (a) and (b). Any limited new text end 89.25 new text begin scope pediatric dental plan that is to be offered to replace a discontinued dental plan under new text end 89.26 new text begin paragraph (b) must be approved by the commissioner of commerce in terms of cost and new text end 89.27 new text begin benefit similarity, and the commissioner of health in terms of network adequacy similarity. new text end 89.28 new text begin The commissioner of health shall enforce paragraph (c). new text end 89.29 new text begin EFFECTIVE DATE. new text end new text begin This section is effective for health plans and dental plans that new text end 89.30 new text begin are offered, sold, issued, or renewed on or after January 1, 2014, with the exception of new text end 89.31 new text begin paragraphs (a) and (b), which are effective for health plans and dental plans that are new text end 89.32 new text begin offered, sold, issued, or renewed on or after January 1, 2015. new text end 89.33    Sec. 16. new text begin [62K.15] ANNUAL OPEN ENROLLMENT PERIODS. new text end 89.34 new text begin (a) Health carriers offering individual health plans must limit annual enrollment in new text end 89.35 new text begin the individual market to the annual open enrollment periods for the Minnesota Insurance new text end 90.1 new text begin Marketplace. Nothing in this section limits the application of special or limited open new text end 90.2 new text begin enrollment periods as defined under the Affordable Care Act. new text end 90.3 new text begin (b) Health carriers offering individual health plans must inform all applicants at the new text end 90.4 new text begin time of application and enrollees at least annually of the open and special enrollment new text end 90.5 new text begin periods as defined under the Affordable Care Act. new text end 90.6 new text begin (c) The commissioner of commerce shall enforce this section. new text end 90.7    Sec. 17. new text begin EFFECTIVE DATE. new text end 90.8 new text begin Sections 1 to 16 are effective for health plans offered, sold, issued, or renewed on or new text end 90.9 new text begin after January 1, 2015, unless otherwise specified. new text end