as introduced - 80th Legislature (1997 - 1998) Posted on 12/15/2009 12:00am
Engrossments | ||
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Introduction | Posted on 02/03/1997 |
1.1 A bill for an act 1.2 relating to health; modifying provisions related to 1.3 health maintenance organizations; amending Minnesota 1.4 Statutes 1996, sections 62D.02, subdivision 10; 1.5 62D.03, subdivisions 3 and 4; 62D.04, subdivision 3; 1.6 62D.042, subdivision 3; 62D.06, subdivision 1; 62D.07, 1.7 subdivision 3; 62D.09, subdivisions 1, 3, and 8; 1.8 62D.102; 62D.11, subdivisions 1, 1b, and 3; 62D.12, by 1.9 adding a subdivision; 62D.20, subdivision 2; 62J.60, 1.10 subdivision 3; 62Q.105; 62Q.106; and 62Q.30; repealing 1.11 Minnesota Statutes 1996, sections 62D.03, subdivision 1.12 2; 62D.11, subdivision 4; and 62Q.11. 1.13 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 1.14 Section 1. Minnesota Statutes 1996, section 62D.02, 1.15 subdivision 10, is amended to read: 1.16 Subd. 10. "Consumer" means any personother than a person1.17(a) whose occupation involves, or before retirement involved,1.18the administration of health activities or the providing of1.19health services; (b) who is, or ever was, employed by a health1.20care facility, as a licensed health professional; or (c) who1.21has, or ever had, a direct, substantial financial or managerial1.22interest in the rendering of health service other than the1.23payment of reasonable expense reimbursement or compensation as a1.24member of the board of a health maintenance organization, 1.25 including an enrollee, to whom a health maintenance organization 1.26 directs marketing materials. 1.27 Sec. 2. Minnesota Statutes 1996, section 62D.03, 1.28 subdivision 3, is amended to read: 1.29 Subd. 3. The commissioner of health may require any person 2.1 providing physician and hospital services with payments made in 2.2 the manner set forth in section 62D.02, subdivision 4, to apply 2.3 for a certificate of authority under sections 62D.01 to 62D.30. 2.4 An applicant may continue to operate until the commissioner of 2.5 health acts upon the application. In the event that an 2.6 application is denied, the applicant shall henceforth be treated 2.7 as a health maintenance organization whose certificate of 2.8 authority has been revoked. Any person directed to apply for a 2.9 certificate of authority shall be subject to the provisions 2.10 of this subdivision2. 2.11 Sec. 3. Minnesota Statutes 1996, section 62D.03, 2.12 subdivision 4, is amended to read: 2.13 Subd. 4. Each application for a certificate of authority 2.14 shall be verified by an officer or authorized representative of 2.15 the applicant, and shall be in a form prescribed by the 2.16 commissioner of health. Each application shall include the 2.17 following: 2.18 (a) a copy of the basic organizational document, if any, of 2.19 the applicant and of each major participating entity; such as 2.20 the articles of incorporation, or other applicable documents, 2.21 and all amendments thereto; 2.22 (b) a copy of the bylaws, rules and regulations, or similar 2.23 document, if any, and all amendments thereto which regulate the 2.24 conduct of the affairs of the applicant and of each major 2.25 participating entity; 2.26 (c) a list of the names, addresses, and official positions 2.27 of the following: 2.28 (1) all members of the board of directors, or governing 2.29 body of the local government unit, and the principal officers 2.30 and shareholders of the applicant organization; and 2.31 (2) all members of the board of directors, or governing 2.32 body of the local government unit, and the principal officers of 2.33 the major participating entity and each shareholder beneficially 2.34 owning more than ten percent of any voting stock of the major 2.35 participating entity; 2.36 The commissioner may by rule identify persons included in 3.1 the term "principal officers"; 3.2 (d) a full disclosure of the extent and nature of any 3.3 contract or financial arrangements between the following: 3.4 (1) the health maintenance organization and the persons 3.5 listed in clause (c)(1); 3.6 (2) the health maintenance organization and the persons 3.7 listed in clause (c)(2); 3.8 (3) each major participating entity and the persons listed 3.9 in clause (c)(1) concerning any financial relationship with the 3.10 health maintenance organization; and 3.11 (4) each major participating entity and the persons listed 3.12 in clause (c)(2) concerning any financial relationship with the 3.13 health maintenance organization; 3.14 (e) the name and address of each participating entity and 3.15 the agreed upon duration of each contract or agreement; 3.16 (f) a copy of the form of each contract binding the 3.17 participating entities and the health maintenance organization. 3.18 Contractual provisions shall be consistent with the purposes of 3.19 sections 62D.01 to 62D.30, in regard to the services to be 3.20 performed under the contract, the manner in which payment for 3.21 services is determined, the nature and extent of 3.22 responsibilities to be retained by the health maintenance 3.23 organization, the nature and extent of risk sharing permissible, 3.24 and contractual termination provisions; 3.25 (g) a copy of each contract binding major participating 3.26 entities and the health maintenance organization. Contract 3.27 information filed with the commissioner shall be confidential 3.28 and subject to the provisions of section 13.37, subdivision 1, 3.29 clause (b), upon the request of the health maintenance 3.30 organization. 3.31 Upon initial filing of each contract, the health 3.32 maintenance organization shall file a separate document 3.33 detailing the projected annual expenses to the major 3.34 participating entity in performing the contract and the 3.35 projected annual revenues received by the entity from the health 3.36 maintenance organization for such performance. The commissioner 4.1 shall disapprove any contract with a major participating entity 4.2 if the contract will result in an unreasonable expense under 4.3 section 62D.19. The commissioner shall approve or disapprove a 4.4 contract within 30 days of filing. 4.5 Within 120 days of the anniversary of the implementation of 4.6 each contract, the health maintenance organization shall file a 4.7 document detailing the actual expenses incurred and reported by 4.8 the major participating entity in performing the contract in the 4.9 preceding year and the actual revenues received from the health 4.10 maintenance organization by the entity in payment for the 4.11 performance.; 4.12Contracts implemented prior to April 25, 1984, shall be4.13filed within 90 days of April 25, 1984. These contracts are4.14subject to the provisions of section 62D.19, but are not subject4.15to the prospective review prescribed by this clause, unless or4.16until the terms of the contract are modified. Commencing with4.17the next anniversary of the implementation of each of these4.18contracts immediately following filing, the health maintenance4.19organization shall, as otherwise required by this subdivision,4.20file annual actual expenses and revenues;4.21 (h) a statement generally describing the health maintenance 4.22 organization, its health maintenance contracts and separate 4.23 health service contracts, facilities, and personnel, including a 4.24 statement describing the manner in which the applicant proposes 4.25 to provide enrollees with comprehensive health maintenance 4.26 services and separate health services; 4.27 (i) a copy of the form of each evidence of coverage to be 4.28 issued to the enrollees; 4.29 (j) a copy of the form of each individual or group health 4.30 maintenance contract and each separate health service contract 4.31 which is to be issued to enrollees or their representatives; 4.32 (k) financial statements showing the applicant's assets, 4.33 liabilities, and sources of financial support. If the 4.34 applicant's financial affairs are audited by independent 4.35 certified public accountants, a copy of the applicant's most 4.36 recent certified financial statement may be deemed to satisfy 5.1 this requirement; 5.2 (l) a description of the proposed method of marketing the 5.3 plan, a schedule of proposed charges, and a financial plan which 5.4 includes a three-year projection of the expenses and income and 5.5 other sources of future capital; 5.6 (m) a statement reasonably describing the geographic area 5.7 or areas to be served and the type or types of enrollees to be 5.8 served; 5.9 (n) a description of the complaint procedures to be 5.10 utilized as required under section 62D.11; 5.11 (o) a description of the procedures and programs to be 5.12 implemented to meet the requirements of section 62D.04, 5.13 subdivision 1, clauses (b) and (c) and to monitor the quality of 5.14 health care provided to enrollees; 5.15 (p) a description of the mechanism by which enrollees will 5.16 be afforded an opportunity to participate in matters of policy 5.17 and operation under section 62D.06; 5.18 (q) a copy of any agreement between the health maintenance 5.19 organization and an insurer or nonprofit health service 5.20 corporation regarding reinsurance, stop-loss coverage, 5.21 insolvency coverage, or any other type of coverage for potential 5.22 costs of health services, as authorized in sections 62D.04, 5.23 subdivision 1, clause (f), 62D.05, subdivision 3, and 62D.13; 5.24 (r) a copy of the conflict of interest policy which applies 5.25 to all members of the board of directors and the principal 5.26 officers of the health maintenance organization, as described in 5.27 section 62D.04, subdivision 1, paragraph (g). All currently 5.28 licensed health maintenance organizations shall also file a 5.29 conflict of interest policy with the commissioner within 60 days 5.30 after August 1, 1990, or at a later date if approved by the 5.31 commissioner; 5.32 (s) a copy of the statement that describes the health 5.33 maintenance organization's prior authorization administrative 5.34 procedures; 5.35 (t) a copy of the agreement between the guaranteeing 5.36 organization and the health maintenance organization, as 6.1 described in section 62D.043, subdivision 6; and 6.2 (u) other information as the commissioner of health may 6.3 reasonably require to be provided. 6.4 Sec. 4. Minnesota Statutes 1996, section 62D.04, 6.5 subdivision 3, is amended to read: 6.6 Subd. 3. Except as provided in section 62D.03, subdivision 6.7 2, no person who has not been issued a certificate of authority 6.8 shall use the words "health maintenance organization" or the 6.9 initials "HMO" in its name, contracts or literature. Provided, 6.10 however, that persons who are operating under a contract with, 6.11 operating in association with, enrolling enrollees for, or 6.12 otherwise authorized by a health maintenance organization 6.13 licensed under sections 62D.01 to 62D.30 to act on its behalf 6.14 may use the terms "health maintenance organization" or "HMO" for 6.15 the limited purpose of denoting or explaining their association 6.16 or relationship with the authorized health maintenance 6.17 organization. No health maintenance organization which has a 6.18 minority ofconsumersenrollees elected according to section 6.19 62D.06, subdivision 1, as members of its board of directors 6.20 shall use the words "consumer controlled" in its name or in any 6.21 way represent to the public that it is controlled by consumers. 6.22 Sec. 5. Minnesota Statutes 1996, section 62D.042, 6.23 subdivision 3, is amended to read: 6.24 Subd. 3. [PHASE-IN FOREXISTING ORGANIZATIONS.](a)6.25Organizations that obtained a certificate of authority on or6.26before April 25, 1988, have until December 31, 1993, to6.27establish a net worth of at least 8-1/3 percent of the sum of6.28all expenses incurred during the previous calendar year, or6.29$1,000,000, whichever is greater.6.30(b) By December 31, 1989, organizations shall have a net6.31worth of at least one-fifth of 8-1/3 percent of the sum of all6.32expenses incurred during the previous calendar year, or6.33$1,000,000, whichever is greater.6.34(c) By December 31, 1990, organizations shall have a net6.35worth of at least two-fifths of 8-1/3 percent of the sum of all6.36expenses incurred during the previous calendar year, or7.1$1,000,000, whichever is greater.7.2(d) By December 31, 1991, organizations shall have a net7.3worth of at least three-fifths of 8-1/3 percent of the sum of7.4all expenses incurred during the previous calendar year, or7.5$1,000,000, whichever is greater.7.6(e) By December 31, 1992, organizationsEach organization 7.7 shall have a net worth of at least four-fifths of 8-1/3 percent 7.8 of the sum of all expenses incurred during the previous calendar 7.9 year, or $1,000,000, whichever is greater. 7.10 Sec. 6. Minnesota Statutes 1996, section 62D.06, 7.11 subdivision 1, is amended to read: 7.12 Subdivision 1. The governing body of any health 7.13 maintenance organization which is a nonprofit corporation may 7.14 include enrollees, providers, or other individuals; provided, 7.15 however, that after a health maintenance organization which is a 7.16 nonprofit corporation has been authorized under sections 62D.01 7.17 to 62D.30 for one year, at least 40 percent of the governing 7.18 body shall be composed ofconsumersenrollees elected by the 7.19 enrollees from among the enrollees. An enrollee elected to the 7.20 governing board may not be a person (1) whose occupation 7.21 involves, or before retirement involved, the administration of 7.22 health activities or the provision of health services; (2) who 7.23 is or was employed by a health care facility as a licensed 7.24 health professional; or (3) who has or had a direct substantial 7.25 financial or managerial interest in the rendering of health 7.26 service, other than the payment of reasonable expense 7.27 reimbursement or compensation as a member of the board of a 7.28 health maintenance organization. 7.29 After a health maintenance organization which is a local 7.30 governmental unit has been authorized under sections 62D.01 to 7.31 62D.30 for one year, an enrollee advisory body shall be 7.32 established. The enrollees who make up this advisory body shall 7.33 be elected by the enrollees from among the enrollees. 7.34 Sec. 7. Minnesota Statutes 1996, section 62D.07, 7.35 subdivision 3, is amended to read: 7.36 Subd. 3. Contracts and evidences of coverage shall contain: 8.1 (a) No provisions or statements which are unjust, unfair, 8.2 inequitable, misleading, deceptive, or which are untrue, 8.3 misleading, or deceptive as defined in section 62D.12, 8.4 subdivision 1;and8.5 (b) A clear, concise and complete statement of: 8.6 (1) the health care services and the insurance or other 8.7 benefits, if any, to which the enrollee is entitled under the 8.8 health maintenance contract; 8.9 (2) any exclusions or limitations on the services, kind of 8.10 services, benefits, or kind of benefits, to be provided, 8.11 including any deductible or copayment feature and requirements 8.12 for referrals, prior authorizations, and second opinions; 8.13 (3) where and in what manner information is available as to 8.14 how services, including emergency and out of area services, may 8.15 be obtained; 8.16 (4) the total amount of payment and copayment, if any, for 8.17 health care services and the indemnity or service benefits, if 8.18 any, which the enrollee is obligated to pay with respect to 8.19 individual contracts, or an indication whether the plan is 8.20 contributory or noncontributory with respect to group 8.21 certificates; and 8.22 (5) a description of the health maintenance organization's 8.23 method for resolving enrollee complaints and a statement 8.24 identifying the commissioner as an external source with whom 8.25grievancescomplaints may be registered.; and 8.26 (c) On the cover page of the evidence of coverage and 8.27 contract, a clear and complete statement of enrollees' rightsas8.28consumers. The statement must be in bold print and captioned 8.29 "ImportantConsumerEnrollee Information and Enrollee Bill of 8.30 Rights" and must include but not be limited to the following 8.31 provisions in the following language or in substantially similar 8.32 language approved in advance by the commissioner: 8.33CONSUMERENROLLEE INFORMATION 8.34 (1) COVERED SERVICES: Services provided by (name of health 8.35 maintenance organization) will be covered only if services are 8.36 provided by participating (name of health maintenance 9.1 organization) providers or authorized by (name of health 9.2 maintenance organization). Your contract fully defines what 9.3 services are covered and describes procedures you must follow to 9.4 obtain coverage. 9.5 (2) PROVIDERS: Enrolling in (name of health maintenance 9.6 organization) does not guarantee services by a particular 9.7 provider on the list of providers. When a provider is no longer 9.8 part of (name of health maintenance organization), you must 9.9 choose among remaining (name of the health maintenance 9.10 organization) providers. 9.11 (3) REFERRALS: Certain services are covered only upon 9.12 referral. See section (section number) of your contract for 9.13 referral requirements. All referrals to non-(name of health 9.14 maintenance organization) providers and certain types of health 9.15 care providers must be authorized by (name of health maintenance 9.16 organization). 9.17 (4) EMERGENCY SERVICES: Emergency services from providers 9.18 who are not affiliated with (name of health maintenance 9.19 organization) will be covered only if proper procedures are 9.20 followed. Your contract explains the procedures and benefits 9.21 associated with emergency care from (name of health maintenance 9.22 organization) and non-(name of health maintenance organization) 9.23 providers. 9.24 (5) EXCLUSIONS: Certain services or medical supplies are 9.25 not covered. You should read the contract for a detailed 9.26 explanation of all exclusions. 9.27 (6) CONTINUATION: You may convert to an individual health 9.28 maintenance organization contract or continue coverage under 9.29 certain circumstances. These continuation and conversion rights 9.30 are explained fully in your contract. 9.31 (7) CANCELLATION: Your coverage may be canceled by you or 9.32 (name of health maintenance organization) only under certain 9.33 conditions. Your contract describes all reasons for 9.34 cancellation of coverage. 9.35 (8) NEWBORN COVERAGE: If your health plan provides for 9.36 dependent coverage, a newborn infant is covered from birth, but 10.1 only if services are provided by participating (name of health 10.2 maintenance organization) providers or authorized by (name of 10.3 health maintenance organization). Certain services are covered 10.4 only upon referral. (Name of health maintenance organization) 10.5 will not automatically know of the infant's birth or that you 10.6 would like coverage under your plan. You should notify (name of 10.7 health maintenance organization) of the infant's birth and that 10.8 you would like coverage. If your contract requires an 10.9 additional premium for each dependent, (name of health 10.10 maintenance organization) is entitled to all premiums due from 10.11 the time of the infant's birth until the time you notify (name 10.12 of health maintenance organization) of the birth. (Name of 10.13 health maintenance organization) may withhold payment of any 10.14 health benefits for the newborn infant until any premiums you 10.15 owe are paid. 10.16 ENROLLEE BILL OF RIGHTS 10.17 (1) Enrollees have the right to available and accessible 10.18 services including emergency services, as defined in your 10.19 contract, 24 hours a day and seven days a week; 10.20 (2) Enrollees have the right to be informed of health 10.21 problems, and to receive information regarding treatment 10.22 alternatives and risks which is sufficient to assure informed 10.23 choice; 10.24 (3) Enrollees have the right to refuse treatment, and the 10.25 right to privacy of medical and financial records maintained by 10.26 the health maintenance organization and its health care 10.27 providers, in accordance with existing law; 10.28 (4) Enrollees have the right to file agrievancecomplaint 10.29 with the health maintenance organization and the commissioner of 10.30 health and the right to initiate a legal proceeding when 10.31 experiencing a problem with the health maintenance organization 10.32 or its health care providers; 10.33 (5) Enrollees have the right to a grace period of 31 days 10.34 for the payment of each premium for an individual health 10.35 maintenance contract falling due after the first premium during 10.36 which period the contract shall continue in force; 11.1 (6) Medicare enrollees have the right to voluntarily 11.2 disenroll from the health maintenance organization and the right 11.3 not to be requested or encouraged to disenroll except in 11.4 circumstances specified in federal law; and 11.5 (7) Medicare enrollees have the right to a clear 11.6 description of nursing home and home care benefits covered by 11.7 the health maintenance organization. 11.8 Sec. 8. Minnesota Statutes 1996, section 62D.09, 11.9 subdivision 1, is amended to read: 11.10 Subdivision 1. (a) Any written marketing materials which 11.11 may be directed toward potential enrollees and which include a 11.12 detailed description of benefits provided by the health 11.13 maintenance organization shall include a statement of 11.14consumerenrollee information and rights as described in section 11.15 62D.07, subdivision 3, paragraphs (b) and (c). Prior to any 11.16 oral marketing presentation, the agent marketing the plan must 11.17 inform the potential enrollees that any complaints concerning 11.18 the material presented should be directed to the health 11.19 maintenance organization, the commissioner of health, or, if 11.20 applicable, the employer. 11.21 (b) Detailed marketing materials must affirmatively 11.22 disclose all exclusions and limitations in the organization's 11.23 services or kinds of services offered to the contracting party, 11.24 including but not limited to the following types of exclusions 11.25 and limitations: 11.26 (1) health care services not provided; 11.27 (2) health care services requiring copayments or 11.28 deductibles paid by enrollees; 11.29 (3) the fact that access to health care services does not 11.30 guarantee access to a particular provider type; and 11.31 (4) health care services that are or may be provided only 11.32 by referral of a physician. 11.33 (c) No marketing materials may lead consumers to believe 11.34 that all health care needs will be covered. All marketing 11.35 materials must alert consumers to possible uncovered expenses 11.36 with the following language in bold print: "THIS HEALTH CARE 12.1 PLAN MAY NOT COVER ALL YOUR HEALTH CARE EXPENSES; READ YOUR 12.2 CONTRACT CAREFULLY TO DETERMINE WHICH EXPENSES ARE COVERED." 12.3 Immediately following the disclosure required under paragraph 12.4 (b), clause (3), consumers must be given a telephone number to 12.5 use to contact the health maintenance organization for specific 12.6 information about access to provider types. 12.7 (d) The disclosures required in paragraphs (b) and (c) are 12.8 not required on billboards or image, and name identification 12.9 advertisement. 12.10 Sec. 9. Minnesota Statutes 1996, section 62D.09, 12.11 subdivision 3, is amended to read: 12.12 Subd. 3. Every health maintenance organization or its 12.13 representative shall annually, before June 1, provide to its 12.14 enrollees the following: (1) a summary of its most recent 12.15 annual financial statement including a balance sheet and 12.16 statement of receipts and disbursements; (2) a description of 12.17 the health maintenance organization, its health care plan or 12.18 plans, its facilities and personnel, any material changes 12.19 therein since the last report; (3) the current evidence of 12.20 coverage or contract; and (4) a statement ofconsumerenrollee 12.21 information and rights as described in section 62D.07, 12.22 subdivision 3, paragraph (c). 12.23 Sec. 10. Minnesota Statutes 1996, section 62D.09, 12.24 subdivision 8, is amended to read: 12.25 Subd. 8. Each health maintenance organization shall issue 12.26 a membership card to its enrollees. The membership card must: 12.27 (1) identify the health maintenance organization; 12.28 (2) include the name, address, and telephone number to call 12.29 if theenrollerenrollee has a complaint; 12.30 (3) include the telephone number to call or the instruction 12.31 on how to receive authorization for emergency care; and 12.32 (4) include one of the following: 12.33 (i) the telephone number to call to appeal to or file a 12.34 complaint with the commissioner of health.; or 12.35 (ii) for persons enrolled under section 256.9363, 256B.69, 12.36 or 256D.03, the telephone numbers to call to appeal to the 13.1 commissioner of human services and to file a complaint with the 13.2 ombudsman designated by the commissioner of human services under 13.3 section 256B.031, who shall annually provide a summary of 13.4 complaints and actions taken to the commissioner of health. 13.5 Sec. 11. Minnesota Statutes 1996, section 62D.102, is 13.6 amended to read: 13.7 62D.102 [MINIMUM BENEFITS.] 13.8 (a)In addition to minimum requirements established in13.9other sections, all group health maintenance contracts providing13.10benefits for mental or nervous disorder treatments in a hospital13.11shall also provide coverage for at least ten hours of treatment13.12over a 12-month period with a copayment not to exceed the13.13greater of $10 or 20 percent of the applicable usual and13.14customary charge for mental or nervous disorder consultation,13.15diagnosis and treatment services delivered while the enrollee is13.16not a bed patient in a hospital and at least 75 percent of the13.17cost of the usual and customary charges for any additional hours13.18of ambulatory mental health treatment during the same 12-month13.19benefit period for serious or persistent mental or nervous13.20disorders. Prior authorization may be required for an extension13.21of coverage beyond ten hours of treatment. This prior13.22authorization must be based upon the severity of the disorder,13.23the patient's risk of deterioration without ongoing treatment13.24and maintenance, degree of functional impairment, and a concise13.25treatment plan. Authorization for extended treatment may be13.26limited to a maximum of 30 visit hours during any 12-month13.27benefit period.All health plans that provide inpatient and 13.28 outpatient mental health and chemical dependency services must 13.29 do so in accordance with the cost-sharing and benefit or service 13.30 limitation requirements of section 62Q.47. 13.31 (b) For purposes of this section, covered treatment for a 13.32 minor includes treatment for the family if family therapy is 13.33 recommended by a health maintenance organization provider. For 13.34 purposes of determining benefits under this section, "hours of 13.35 treatment" means treatment rendered on an individual or 13.36 single-family basis. If treatment is rendered on a group basis, 14.1 the hours of covered group treatment must be provided at a ratio 14.2 of no less than two group treatment sessions to one individual 14.3 treatment hour. For a health maintenance contract that is 14.4 offered as a companion to a health insurance subscriber 14.5 contract, the benefits for mental or nervous disorders must be 14.6 calculated in aggregate for the health maintenance contract and 14.7 the health insurance subscriber contract. 14.8 Sec. 12. Minnesota Statutes 1996, section 62D.11, 14.9 subdivision 1, is amended to read: 14.10 Subdivision 1. [ENROLLEE COMPLAINT SYSTEM.] Every health 14.11 maintenance organization shall establish and maintain a 14.12 complaint system, as required under section 62Q.105 to provide 14.13 reasonable procedures for the resolution of written complaints 14.14 initiated by or on behalf of enrollees concerning the provision 14.15 of health care services. "Provision of health services" 14.16 includes, but is not limited to, questions of the scope of 14.17 coverage, quality of care, and administrative operations. The 14.18 health maintenance organization must inform enrollees that they 14.19 may choose to useanalternative dispute resolutionprocessto 14.20 appeal a health maintenance organization's internal appeal 14.21 decision. If an enrollee chooses to use an alternative dispute 14.22 resolution process, the health maintenance organization must 14.23 participate. 14.24 Sec. 13. Minnesota Statutes 1996, section 62D.11, 14.25 subdivision 1b, is amended to read: 14.26 Subd. 1b. [EXPEDITED RESOLUTION OF COMPLAINTS ABOUT 14.27URGENTLY NEEDED SERVICEMEDICALLY URGENT SERVICES.] In addition 14.28 to any remedy contained in subdivision 1a, when a complaint 14.29 involves a dispute about a health maintenance organization's 14.30 coverage of an immediately and urgently needed service, the 14.31 commissioner may also order the health maintenance organization 14.32 to use an expedited system to process the complaint. 14.33 Sec. 14. Minnesota Statutes 1996, section 62D.11, 14.34 subdivision 3, is amended to read: 14.35 Subd. 3. [DENIAL OFSERVICECOVERAGE.] Within a reasonable 14.36 time after receiving an enrollee's written or oral communication 15.1 to the health maintenance organization concerning arefusal15.2 denial ofservicecoverage or inadequacy of services, the health 15.3 maintenance organization shall provide the enrollee with a 15.4 written statement of the reason for therefusaldenial of 15.5servicecoverage, and a statement approved by the commissioner 15.6 of health which explains the health maintenance organization 15.7 complaint procedures, and in the case of Medicare enrollees, 15.8 which also explains Medicare appeal procedures. 15.9 Sec. 15. Minnesota Statutes 1996, section 62D.12, is 15.10 amended by adding a subdivision to read: 15.11 Subd. 19. [COVERAGE OF SERVICE.] A health maintenance 15.12 organization may not deny or limit coverage of a service which 15.13 the enrollee has already received solely on the basis of lack of 15.14 prior authorization or second opinion, to the extent that the 15.15 service would otherwise have been covered under the member's 15.16 contract by the health maintenance organization had prior 15.17 authorization or second opinion been obtained. 15.18 Sec. 16. Minnesota Statutes 1996, section 62D.20, 15.19 subdivision 2, is amended to read: 15.20 Subd. 2. [PRIOR AUTHORIZATION.] The commissioner shall 15.21 adopt rules that address the issue of appropriate prior 15.22 authorization requirements, consideringconsumerenrollee needs, 15.23 administrative concerns, and the nature of the benefit. 15.24 Sec. 17. Minnesota Statutes 1996, section 62J.60, 15.25 subdivision 3, is amended to read: 15.26 Subd. 3. [HUMAN READABLE DATA ELEMENTS.] (a) The following 15.27 are the minimum human readable data elements that must be 15.28 present on the front side of the Minnesota health care 15.29 identification card: 15.30 (1) card issuer name or logo, which is the name or logo 15.31 that identifies the card issuer. The card issuer name or logo 15.32 may be the card's front background. No standard label is 15.33 required for this data element; 15.34 (2) claim submission number. The standardized label for 15.35 this element is "Clm Subm #"; 15.36 (3) identification number, which is the unique 16.1 identification number of the individual card holder established 16.2 and defined under this section. The standardized label for the 16.3 data element is "ID"; 16.4 (4) identification name, which is the name of the 16.5 individual card holder. The identification name must be 16.6 formatted as follows: first name, space, optional middle 16.7 initial, space, last name, optional space and name suffix. The 16.8 standardized label for this data element is "Name"; 16.9 (5) account number(s), which is any other number, such as a 16.10 group number, if required for part of the identification or 16.11 claims process. The standardized label for this data element is 16.12 "Account"; 16.13 (6) care type, which is the description of the group 16.14 purchaser's plan product under which the beneficiary is 16.15 covered. The description shall include the health plan company 16.16 name and the plan or product name. The standardized label for 16.17 this data element is "Care Type"; 16.18 (7) service type, which is the description of coverage 16.19 provided such as hospital, dental, vision, prescription, or 16.20 mental health. The standard label for this data element is "Svc 16.21 Type"; and 16.22 (8) provider/clinic name, which is the name of the primary 16.23 care clinic the card holder is assigned to by the health plan 16.24 company. The standard label for this field is "PCP." This 16.25 information is mandatory only if the health plan company assigns 16.26 a specific primary care provider to the card holder. 16.27 (b) The following human readable data elements shall be 16.28 present on the back side of the Minnesota health identification 16.29 card. These elements must be left justified, and no optional 16.30 data elements may be interspersed between them: 16.31 (1) claims submission name(s) and address(es), which are 16.32 the name(s) and address(es) of the entity or entities to which 16.33 claims should be submitted. If different destinations are 16.34 required for different types of claims, this must be 16.35 labeled; and 16.36 (2) telephone number(s) and name(s); which are the 17.1 telephone number(s) and name(s) of the following contact(s) with 17.2 a standardized label describing the service function as 17.3 applicable: 17.4 (i) eligibility and benefit information; 17.5 (ii) utilization review; 17.6 (iii) precertification; or 17.7 (iv) customer services. 17.8 (c) The following human readable data elements are 17.9 mandatory on the back side of the card for health maintenance 17.10 organizations and integrated service networks: 17.11 (1) emergency care authorization telephone number or 17.12 instruction on how to receive authorization for emergency care. 17.13 There is no standard label required for this information; and 17.14 (2) one of the following: 17.15 (i) telephone number to call to appeal to or file a 17.16 complaint with the commissioner of health; or 17.17 (ii) for persons enrolled under sections 256.9363, 256B.69, 17.18 or 256D.03, telephone numbers to call to appeal to the 17.19 commissioner of human services and to file a complaint with the 17.20 ombudsman designated by the commissioner of human services under 17.21 section 256B.031, who shall annually provide a summary of 17.22 complaints and the actions taken to the commissioner of health. 17.23 There is no standard label required for this information. 17.24 (d) All human readable data elements not required under 17.25 paragraphs (a) to (c) are optional and may be used at the 17.26 issuer's discretion. 17.27 Sec. 18. Minnesota Statutes 1996, section 62Q.105, is 17.28 amended to read: 17.29 62Q.105 [HEALTH PLAN COMPANY COMPLAINT PROCEDURE.] 17.30 Subdivision 1. [ESTABLISHMENT.] Each health plan company 17.31 shall establish and make available to enrollees, by July 1, 17.32 1997, an informal complaint resolution process that meets the 17.33 requirements of this section. A health plan company must make 17.34 reasonable efforts to resolve enrollee complaints, and must 17.35 inform complainants in writing of the company's decision and the 17.36 reasons for it within 30 days of receiving the complaint. The 18.1 complaint resolution process must treat the complaint and 18.2 information related to it as required under sections 72A.49 to 18.3 72A.505. 18.4 Subd. 2. [MEDICALLY URGENT COMPLAINTS.] A medically urgent 18.5 complaint involves medically necessary care which does not meet 18.6 the definition of emergency care but is needed as soon as 18.7 possible, usually within 24 hours, to protect the health of the 18.8 enrollee. Health plan companies shall make reasonable efforts 18.9 to promptly resolve medically urgent enrollee complaintswithin18.1072 hoursand promptly notify the enrollee and the commissioner 18.11 of their decisions, but in no case later than three business 18.12 days of receiving the complaint. 18.13 Subd. 3. [APPEALS PROCESS.] Health plan companies shall 18.14 establish and make available to enrollees animpartialinternal 18.15 appeals process. If a decision by a health plan company 18.16 regarding a complaint is partially or wholly adverse to the 18.17 complainant, the health plan company shall advise the 18.18 complainant ofthe right toadditional appealthrough the18.19impartial appeals process or to the commissioner.mechanisms 18.20 under this section. The person or persons conducting the appeal 18.21 must have the authority to resolve or recommend the resolution 18.22 of the complaint and must not be solely the person or persons 18.23 who decided the enrollee's original complaint. A health plan 18.24 company must inform the enrollee of the outcome of an internal 18.25 appeal in writing, and the reasons for it, within 45 days of 18.26 receiving the appeal. A health plan company must explain 18.27 Medicare appeal procedures to its Medicare enrollees. For 18.28 persons enrolled in health care programs established under 18.29 section 256.9363, 256B.69, or 256D.03, a health plan company 18.30 must explain how to contact the managed care ombudsman at the 18.31 department of human services. 18.32 Subd. 4. [ALTERNATIVE DISPUTE RESOLUTION.] Health plan 18.33 companies shall make available to enrollees an alternative 18.34 dispute resolution process according to subdivision 10 to appeal 18.35 health plan company internal appeal decisions, and shall 18.36 participate in that alternative dispute resolution at the 19.1 request of an enrollee, as required under section 62Q.11. A 19.2 health plan company must respond within 14 days of receiving the 19.3 enrollee's request for alternative dispute resolution and inform 19.4 the enrollee of the options available. A health plan company 19.5 may meet the requirements of subdivision 3 by providing an 19.6 alternative dispute resolution process. If the health plan19.7company chooses to provide alternative dispute resolution to19.8meet the requirements of subdivision 3, the process shall be19.9providedat no cost to the enrollee. 19.10 Subd. 5. [REQUIREMENTS FOR MANAGED CARE ORGANIZATIONS.] 19.11 Each managed care organization shall submit all health care 19.12 quality related complaints to its quality review board or 19.13 quality review organization for evaluation and possible action. 19.14 The complaint resolution process for managed care organizations 19.15 must clearly indicate the entity responsible for resolving 19.16 complaints made by enrollees against hospitals, other health 19.17 care facilities, and health care providers, that are owned by or 19.18 under contract with the managed care organization. 19.19 Subd. 6. [RECORDKEEPING.] Health plan companies shall 19.20 maintain records of all enrollee complaints and their 19.21 resolutions. These records must be retained for five years, and 19.22 must be made available to theappropriatecommissioner upon 19.23 request. 19.24 Subd. 7. [REPORTING.] Each health plan company shall 19.25 submit to theappropriatecommissioner, as part of the company's 19.26 annual filing, data on the number and type of complaints that 19.27 are not resolved within 30 days. A health plan company shall 19.28 also make this information available to the public upon request. 19.29 Subd. 8. [NOTICE TO ENROLLEES.] Health plan companies 19.30 shall provide a clear and complete description of their 19.31 complaint resolution procedures to enrollees as part of their 19.32 evidence of coverage or contract. The description must 19.33 specifically inform enrollees: 19.34 (1) how to file a complaint with the health plan company; 19.35 (2) how to request animpartialinternal appeal; 19.36 (3) how to appeal to or file a complaint with the 20.1 commissioner and that they have the right to request the use of 20.2 alternative methods of dispute resolution following an internal 20.3 appeal; and 20.4 (4) that they have the right to litigate. 20.5 Subd. 9. [PROCEDURE.] (a) When an enrollee files a 20.6 complaint with the health plan company and receives the written 20.7 response to the complaint, the enrollee may appeal through the 20.8 health plan company's internal appeal process. 20.9 (b) When an enrollee files a complaint with the 20.10 commissioner, the commissioner shall investigate the complaint 20.11 and inform the enrollee and the health plan company of the 20.12 commissioner's decision. An enrollee who receives the 20.13 commissioner's decision may appeal through the health plan 20.14 company's internal appeal process. 20.15 (c) An enrollee may appeal the result of the health plan 20.16 company's internal appeal process to the commissioner or to 20.17 alternative dispute resolution. 20.18 (d) Procedures under this section are stayed when an 20.19 enrollee files suit, including suit in conciliation court, 20.20 against a health plan company, or when the enrollee makes the 20.21 health plan company a party to the enrollee's suit against 20.22 another party concerning the facts giving rise to the enrollee's 20.23 complaint. Upon a decision on the merits, the enrollee shall be 20.24 deemed to have waived the remedies under this section. If an 20.25 enrollee's case is dismissed for reasons other than on the 20.26 merits or if the enrollee and health plan company agree, an 20.27 enrollee may access the procedures under this section. 20.28 Subd. 10. [ENROLLEE DISPUTE RESOLUTION.] (a) For purposes 20.29 of this section and chapter 62D, "alternative dispute 20.30 resolution" means the methods listed and defined in Minnesota 20.31 General Rules of Practice, rule 114. 20.32 (b) Alternative dispute resolution is binding, unless the 20.33 parties mutually agree in advance in writing that alternative 20.34 dispute resolution is not binding. 20.35 (c) Enrollee complaints regarding employer initiated 20.36 actions, agent misrepresentation, or premiums are not subject to 21.1 alternative dispute resolution. A medical malpractice damage 21.2 claim is not subject to alternative dispute resolution unless 21.3 agreed to by all parties subsequent to the event giving rise to 21.4 the claim. 21.5 (d) A health plan company shall inform and educate its 21.6 enrollees about alternative dispute resolution and its benefits. 21.7 (e) The enrollee and the health plan company shall mutually 21.8 agree to the alternative dispute method to resolve the 21.9 enrollee's appeal within 14 days of the enrollee's receipt of 21.10 alternative dispute resolution options. Mediation-arbitration 21.11 shall be used if the enrollee and the health plan company cannot 21.12 agree. The alternative dispute resolution must be scheduled as 21.13 soon as possible after the parties agree to a method. A health 21.14 plan company must inform the enrollee of the outcome of an 21.15 alternative dispute resolution in writing, and the reasons for 21.16 it, within ten calendar days of receiving the outcome from the 21.17 alternative dispute resolution provider. 21.18 Subd. 11. [PROVIDER DISPUTE RESOLUTION.] When a health 21.19 care provider under a contract has a dispute with a health plan 21.20 company that is governed neither by the federal Health Care 21.21 Quality Improvement Act of 1986, United States Code, title 42, 21.22 sections 11101 to 11152, nor by a contract between the provider 21.23 and the health plan company, the provider may request an 21.24 alternative dispute resolution process. The health plan company 21.25 must participate. The health care provider and the health plan 21.26 company shall mutually agree to one of the alternative dispute 21.27 resolution methods listed in subdivision 10 within 30 calendar 21.28 days of the health plan company receiving the request for 21.29 alternative dispute resolution. If the provider and the health 21.30 plan company cannot agree on the alternative dispute resolution 21.31 method, mediation-arbitration shall be used. Alternative 21.32 dispute resolution under this subdivision is binding unless the 21.33 parties mutually agree in advance in writing that alternative 21.34 dispute resolution is not binding. 21.35 Sec. 19. Minnesota Statutes 1996, section 62Q.106, is 21.36 amended to read: 22.1 62Q.106 [DISPUTE RESOLUTION BY COMMISSIONERCOMMISSIONER'S 22.2 RESPONSIBILITY TO INVESTIGATE ENROLLEE COMPLAINTS.] 22.3 A complainant may at any time prior to binding alternative 22.4 dispute resolution or a judicial decision on the merits, submit 22.5 a complaint to theappropriatecommissioner to investigate. The 22.6 commissioner may investigate an enrollee complaint or enrollee 22.7 appeal of the health plan company's internal appeal decision. 22.8 When the complaint concerns the health plan company's decision 22.9 to not cover a service, the appropriate commissioner may review 22.10 the complaint and any information, including testimony, 22.11 necessary to resolve the complaint. After investigating a 22.12 complaint, or reviewing a company's decision, theappropriate22.13 commissioner may order a remedy as authorized under section 22.1462N.04,62Q.30, chapter 45, 60A, or 62D. 22.15 Sec. 20. Minnesota Statutes 1996, section 62Q.30, is 22.16 amended to read: 22.17 62Q.30 [EXPEDITED FACT FINDING AND DISPUTE RESOLUTION 22.18 PROCESS.] 22.19 (a) The commissioner shall establish an expedited fact 22.20 finding and dispute resolution process to assist enrollees of 22.21 health plan companies with contested medically urgent treatment, 22.22 coverage, and service issues to be in effect July 1, 22.23 1997. "Medically urgent" has the meaning given in section 22.24 62Q.105, subdivision 2. 22.25 (b) The commissioner may orderan integrated service22.26network or an all-payer insurera health plan company to provide 22.27 or pay for a service that iswithin the standard health coverage22.28 either required to be provided by law or covered under the 22.29 enrollee's evidence of coverage. The commissioner shall take 22.30 steps including, but not limited to, fining, suspending, or 22.31 revoking the license of a health plan company that is the 22.32 subject of repeated orders by the commissioner that suggest a 22.33 pattern of inappropriate underutilization. 22.34 (c) If the disputed issue relates to whether a service is 22.35 appropriate and necessary, the commissioner shall issue an order 22.36 only after consulting with appropriate experts knowledgeable, 23.1 trained, and practicing in the area in dispute, reviewing 23.2 pertinent literature, and considering the availability of 23.3 satisfactory alternatives.The commissioner shall take steps23.4including but not limited to fining, suspending, or revoking the23.5license of a health plan company that is the subject of repeated23.6orders by the commissioner that suggests a pattern of23.7inappropriate underutilization.23.8 (d) Procedures under this section are stayed when an 23.9 enrollee files suit, including suit in conciliation court, 23.10 against a health plan company or when the enrollee makes the 23.11 health plan company a party to the enrollee's suit against 23.12 another party concerning the facts giving rise to the enrollee's 23.13 complaint. Upon a decision on the merits, the enrollee shall be 23.14 deemed to have waived the remedies under this section. If an 23.15 enrollee's case is dismissed for reasons other than on the 23.16 merits or if the enrollee and the health plan company agree, an 23.17 enrollee may access the procedures under this section. 23.18 Sec. 21. [REPEALER.] 23.19 Minnesota Statutes 1996, sections 62D.03, subdivision 2; 23.20 62D.11, subdivision 4; and 62Q.11, are repealed.