3rd Engrossment - 81st Legislature (1999 - 2000) Posted on 12/15/2009 12:00am
Engrossments | ||
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Introduction | Posted on 02/25/1999 | |
1st Engrossment | Posted on 03/16/1999 | |
2nd Engrossment | Posted on 03/24/1999 | |
3rd Engrossment | Posted on 03/30/1999 |
1.1 A bill for an act 1.2 relating to insurance; transferring regulatory 1.3 authority over health maintenance organizations and 1.4 similar entities to the commissioner of commerce; 1.5 making conforming changes; requiring a report; 1.6 amending Minnesota Statutes 1998, sections 60B.02; 1.7 60B.03, subdivisions 2 and 4; 60B.15; 60B.20; 60G.01, 1.8 subdivisions 2 and 4; 62A.61; 62D.01, subdivision 2; 1.9 62D.02, subdivision 3, and by adding a subdivision; 1.10 62D.03, subdivisions 1, 3, and 4; 62D.04, subdivisions 1.11 1, 2, 4, and by adding a subdivision; 62D.05, 1.12 subdivision 6; 62D.06, subdivision 2; 62D.07, 1.13 subdivisions 2, 3, and 10; 62D.08, subdivisions 1, 2, 1.14 3, 4, and 5; 62D.09, subdivisions 1 and 8; 62D.10, 1.15 subdivision 4; 62D.11, subdivisions 1b, 2, 3, and by 1.16 adding a subdivision; 62D.12, subdivisions 1, 2, and 1.17 9; 62D.121, subdivisions 3a and 7; 62D.14, 1.18 subdivisions 1, 3, 4, 5, and 6; 62D.15, subdivisions 1 1.19 and 4; 62D.16, subdivisions 1 and 2; 62D.17, 1.20 subdivisions 1, 3, 4, and 5; 62D.18, subdivisions 1 1.21 and 7; 62D.19; 62D.20, subdivision 1; 62D.21; 62D.211; 1.22 62D.22, subdivisions 4 and 10; 62D.24; 62D.30, 1.23 subdivisions 1 and 3; 62L.02, subdivision 8; 62L.05, 1.24 subdivision 12; 62L.08, subdivisions 10 and 11; 1.25 62M.11; 62M.16; 62N.02, subdivision 4; 62N.26; 62N.31, 1.26 subdivision 1; 62Q.01, subdivision 2; 62Q.07; 62Q.075, 1.27 subdivision 4; 62Q.105, subdivisions 6 and 7; 62Q.11; 1.28 62Q.22, subdivisions 2, 6, and 7; 62Q.32; 62Q.51, 1.29 subdivision 3; 62Q.525, subdivision 3; 62R.04, 1.30 subdivision 5; 62R.25; 62T.01, subdivision 4; and 1.31 72A.139, subdivision 2; repealing Minnesota Statutes 1.32 1998, sections 62D.18; 62L.11, subdivision 2; and 1.33 62Q.45, subdivision 1. 1.34 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 1.35 ARTICLE 1 1.36 HEALTH MAINTENANCE ORGANIZATIONS 1.37 Section 1. Minnesota Statutes 1998, section 62D.01, 1.38 subdivision 2, is amended to read: 1.39 Subd. 2. (a) Faced with the continuation of mounting costs 2.1 of health care coupled with its inaccessibility to large 2.2 segments of the population, the legislature has determined that 2.3 there is a need to explore alternative methods for the delivery 2.4 of health care services, with a view toward achieving greater 2.5 efficiency and economy in providing these services. 2.6 (b) It is, therefore, the policy of the state to eliminate 2.7 the barriers to the organization, promotion, and expansion of 2.8 health maintenance organizations; to provide for their 2.9 regulation by the state commissioner ofhealthcommerce and the 2.10 state commissioner of health; and to exempt them from the 2.11 operation of the insurance and nonprofit health service plan 2.12 corporation laws of the state except as hereinafter provided. 2.13 (c) It is further the intention of the legislature to 2.14 closely monitor the development of health maintenance 2.15 organizations in order to assess their impact on the costs of 2.16 health care to consumers, the accessibility of health care to 2.17 consumers, and the quality of health care provided to consumers. 2.18 Sec. 2. Minnesota Statutes 1998, section 62D.02, 2.19 subdivision 3, is amended to read: 2.20 Subd. 3. "Commissioner ofhealthcommerce" or 2.21 "commissioner" means the state commissioner ofhealthcommerce 2.22 or a designee. 2.23 Sec. 3. Minnesota Statutes 1998, section 62D.02, is 2.24 amended by adding a subdivision to read: 2.25 Subd. 17. [QUALITY OF CARE.] "Quality of care" means the 2.26 degree to which health services for individuals and populations 2.27 are consistent with current professional knowledge and accepted 2.28 standards for: 2.29 (1) availability and access to provider network and care 2.30 management systems; 2.31 (2) provider credentialing and monitoring procedures and 2.32 needs of the community and individuals served; 2.33 (3) process for appropriate, effective, patient-centered 2.34 care delivery consistent with accepted practice parameters; and 2.35 (4) patient satisfaction and increased likelihood of 2.36 desired clinical and functional outcomes. 3.1 Sec. 4. Minnesota Statutes 1998, section 62D.03, 3.2 subdivision 1, is amended to read: 3.3 Subdivision 1. Notwithstanding any law of this state to 3.4 the contrary, any nonprofit corporation organized to do so or a 3.5 local governmental unit may apply to the commissionerof health3.6 for a certificate of authority to establish and operate a health 3.7 maintenance organization in compliance with sections 62D.01 to 3.8 62D.30. No person shall establish or operate a health 3.9 maintenance organization in this state, nor sell or offer to 3.10 sell, or solicit offers to purchase or receive advance or 3.11 periodic consideration in conjunction with a health maintenance 3.12 organization or health maintenance contract unless the 3.13 organization has a certificate of authority under sections 3.14 62D.01 to 62D.30. 3.15 Sec. 5. Minnesota Statutes 1998, section 62D.03, 3.16 subdivision 3, is amended to read: 3.17 Subd. 3. The commissioner or commissioner of health may 3.18 require any person providing physician and hospital services 3.19 with payments made in the manner set forth in section 62D.02, 3.20 subdivision 4, to apply for a certificate of authority under 3.21 sections 62D.01 to 62D.30. An applicant may continue to operate 3.22 until the commissionerof healthacts upon the application. In 3.23 the event that an application is denied, the applicant shall 3.24 henceforth be treated as a health maintenance organization whose 3.25 certificate of authority has been revoked. Any person directed 3.26 to apply for a certificate of authority shall be subject to the 3.27 provisions of this subdivision. 3.28 Sec. 6. Minnesota Statutes 1998, section 62D.03, 3.29 subdivision 4, is amended to read: 3.30 Subd. 4. Each application for a certificate of authority 3.31 shall be verified by an officer or authorized representative of 3.32 the applicant, and shall be in a form prescribed by the 3.33 commissionerof health. Each application shall include the 3.34 following: 3.35 (a) a copy of the basic organizational document, if any, of 3.36 the applicant and of each major participating entity; such as 4.1 the articles of incorporation, or other applicable documents, 4.2 and all amendments thereto; 4.3 (b) a copy of the bylaws, rules and regulations, or similar 4.4 document, if any, and all amendments thereto which regulate the 4.5 conduct of the affairs of the applicant and of each major 4.6 participating entity; 4.7 (c) a list of the names, addresses, and official positions 4.8 of the following: 4.9 (1) all members of the board of directors, or governing 4.10 body of the local government unit, and the principal officers 4.11 and shareholders of the applicant organization; and 4.12 (2) all members of the board of directors, or governing 4.13 body of the local government unit, and the principal officers of 4.14 the major participating entity and each shareholder beneficially 4.15 owning more than ten percent of any voting stock of the major 4.16 participating entity; 4.17 The commissioner may by rule identify persons included in 4.18 the term "principal officers"; 4.19 (d) a full disclosure of the extent and nature of any 4.20 contract or financial arrangements between the following: 4.21 (1) the health maintenance organization and the persons 4.22 listed in clause (c)(1); 4.23 (2) the health maintenance organization and the persons 4.24 listed in clause (c)(2); 4.25 (3) each major participating entity and the persons listed 4.26 in clause (c)(1) concerning any financial relationship with the 4.27 health maintenance organization; and 4.28 (4) each major participating entity and the persons listed 4.29 in clause (c)(2) concerning any financial relationship with the 4.30 health maintenance organization; 4.31 (e) the name and address of each participating entity and 4.32 the agreed upon duration of each contract or agreement; 4.33 (f) a copy of the form of each contract binding the 4.34 participating entities and the health maintenance organization. 4.35 Contractual provisions shall be consistent with the purposes of 4.36 sections 62D.01 to 62D.30, in regard to the services to be 5.1 performed under the contract, the manner in which payment for 5.2 services is determined, the nature and extent of 5.3 responsibilities to be retained by the health maintenance 5.4 organization, the nature and extent of risk sharing permissible, 5.5 and contractual termination provisions; 5.6 (g) a copy of each contract binding major participating 5.7 entities and the health maintenance organization. Contract 5.8 information filed with the commissioner shall be confidential 5.9 and subject to the provisions of section 13.37, subdivision 1, 5.10 clause (b), upon the request of the health maintenance 5.11 organization. 5.12 Upon initial filing of each contract, the health 5.13 maintenance organization shall file a separate document 5.14 detailing the projected annual expenses to the major 5.15 participating entity in performing the contract and the 5.16 projected annual revenues received by the entity from the health 5.17 maintenance organization for such performance. The commissioner 5.18 shall disapprove any contract with a major participating entity 5.19 if the contract will result in an unreasonable expense under 5.20 section 62D.19. The commissioner shall approve or disapprove a 5.21 contract within 30 days of filing. 5.22 Within 120 days of the anniversary of the implementation of 5.23 each contract, the health maintenance organization shall file a 5.24 document detailing the actual expenses incurred and reported by 5.25 the major participating entity in performing the contract in the 5.26 preceding year and the actual revenues received from the health 5.27 maintenance organization by the entity in payment for the 5.28 performance; 5.29 (h) a statement generally describing the health maintenance 5.30 organization, its health maintenance contracts and separate 5.31 health service contracts, facilities, and personnel, including a 5.32 statement describing the manner in which the applicant proposes 5.33 to provide enrollees with comprehensive health maintenance 5.34 services and separate health services; 5.35 (i) a copy of the form of each evidence of coverage to be 5.36 issued to the enrollees; 6.1 (j) a copy of the form of each individual or group health 6.2 maintenance contract and each separate health service contract 6.3 which is to be issued to enrollees or their representatives; 6.4 (k) financial statements showing the applicant's assets, 6.5 liabilities, and sources of financial support. If the 6.6 applicant's financial affairs are audited by independent 6.7 certified public accountants, a copy of the applicant's most 6.8 recent certified financial statement may be deemed to satisfy 6.9 this requirement; 6.10 (l) a description of the proposed method of marketing the 6.11 plan, a schedule of proposed charges, and a financial plan which 6.12 includes a three-year projection of the expenses and income and 6.13 other sources of future capital; 6.14 (m) a statement reasonably describing the geographic area 6.15 or areas to be served and the type or types of enrollees to be 6.16 served; 6.17 (n) a description of the complaint procedures to be 6.18 utilized as required under section 62D.11; 6.19 (o) a description of the procedures and programs to be 6.20 implemented to meet the requirements of section 62D.04, 6.21subdivision 1, clauses (b) and (c)subdivision 1a, paragraph 6.22 (a), clauses (1) and (2), and to monitor the quality of health 6.23 care provided to enrollees; 6.24 (p) a description of the mechanism by which enrollees will 6.25 be afforded an opportunity to participate in matters of policy 6.26 and operation under section 62D.06; 6.27 (q) a copy of any agreement between the health maintenance 6.28 organization and an insurer or nonprofit health service 6.29 corporation regarding reinsurance, stop-loss coverage, 6.30 insolvency coverage, or any other type of coverage for potential 6.31 costs of health services, as authorized in sections 62D.04, 6.32 subdivision 1, clause (f), 62D.05, subdivision 3, and 62D.13; 6.33 (r) a copy of the conflict of interest policy which applies 6.34 to all members of the board of directors and the principal 6.35 officers of the health maintenance organization, as described in 6.36 section 62D.04, subdivision 1, paragraph (g). All currently7.1licensed health maintenance organizations shall also file a7.2conflict of interest policy with the commissioner within 60 days7.3after August 1, 1990, or at a later date if approved by the7.4commissioner; 7.5 (s) a copy of the statement that describes the health 7.6 maintenance organization's prior authorization administrative 7.7 procedures; 7.8 (t) a copy of the agreement between the guaranteeing 7.9 organization and the health maintenance organization, as 7.10 described in section 62D.043, subdivision 6; and 7.11 (u) other information as the commissionerof healthmay 7.12 reasonably require to be provided. 7.13 Sec. 7. Minnesota Statutes 1998, section 62D.04, 7.14 subdivision 1, is amended to read: 7.15 Subdivision 1. Upon receipt of an application for a 7.16 certificate of authority, the commissionerof healthshall 7.17 determine whether the applicant for a certificate of authority 7.18 has: 7.19(a) demonstrated the willingness and potential ability to7.20assure that health care services will be provided in such a7.21manner as to enhance and assure both the availability and7.22accessibility of adequate personnel and facilities;7.23(b) arrangements for an ongoing evaluation of the quality7.24of health care;7.25(c) a procedure to develop, compile, evaluate, and report7.26statistics relating to the cost of its operations, the pattern7.27of utilization of its services, the quality, availability and7.28accessibility of its services, and such other matters as may be7.29reasonably required by regulation of the commissioner of health;7.30(d) reasonable provisions for emergency and out of area7.31health care services;7.32(e)(a) demonstrated that it is financially responsible and 7.33 may reasonably be expected to meet its obligations to enrollees 7.34 and prospective enrollees. In making this determination, the 7.35 commissionerof healthshall require the amounts of net worth 7.36 and working capital required in section 62D.042, the deposit 8.1 required in section 62D.041, and in addition shall consider: 8.2 (1) the financial soundness of its arrangements for health 8.3 care services and the proposed schedule of charges used in 8.4 connection therewith; 8.5 (2) arrangements which will guarantee for a reasonable 8.6 period of time the continued availability or payment of the cost 8.7 of health care services in the event of discontinuance of the 8.8 health maintenance organization; and 8.9 (3) agreements with providers for the provision of health 8.10 care services; 8.11(f)(b) demonstrated that it will assume full financial 8.12 risk on a prospective basis for the provision of comprehensive 8.13 health maintenance services, including hospital care; provided, 8.14 however, that the requirement in this paragraph shall not 8.15 prohibit the following: 8.16 (1) a health maintenance organization from obtaining 8.17 insurance or making other arrangements (i) for the cost of 8.18 providing to any enrollee comprehensive health maintenance 8.19 services, the aggregate value of which exceeds $5,000 in any 8.20 year, (ii) for the cost of providing comprehensive health care 8.21 services to its members on a nonelective emergency basis, or 8.22 while they are outside the area served by the organization, or 8.23 (iii) for not more than 95 percent of the amount by which the 8.24 health maintenance organization's costs for any of its fiscal 8.25 years exceed 105 percent of its income for such fiscal years; 8.26 and 8.27 (2) a health maintenance organization from having a 8.28 provision in a group health maintenance contract allowing an 8.29 adjustment of premiums paid based upon the actual health 8.30 services utilization of the enrollees covered under the 8.31 contract, except that at no time during the life of the contract 8.32 shall the contract holder fully self-insure the financial risk 8.33 of health care services delivered under the contract. Risk 8.34 sharing arrangements shall be subject to the requirements of 8.35 sections 62D.01 to 62D.30; 8.36(g)(c) demonstrated that it has made provisions for and 9.1 adopted a conflict of interest policy applicable to all members 9.2 of the board of directors and the principal officers of the 9.3 health maintenance organization. The conflict of interest 9.4 policy shall include the procedures described in section 9.5 317A.255, subdivisions 1 and 2. However, the commissioner is 9.6 not precluded from finding that a particular transaction is an 9.7 unreasonable expense as described in section 62D.19 even if the 9.8 directors follow the required procedures; and 9.9(h)(d) otherwise met the requirements of sections 62D.01 9.10 to 62D.30. 9.11 Sec. 8. Minnesota Statutes 1998, section 62D.04, is 9.12 amended by adding a subdivision to read: 9.13 Subd. 1a. [REVIEW BY COMMISSIONER OF HEALTH.] (a) Upon 9.14 receipt of an application for a certificate of authority, the 9.15 commissioner shall request that the commissioner of health 9.16 certify whether the applicant has: 9.17 (1) demonstrated the willingness and potential ability to 9.18 assure that health care services will be provided in such a 9.19 manner so as to enhance and assure both the availability and 9.20 accessibility of adequate personnel and facilities; 9.21 (2) arrangements for an ongoing evaluation of the quality 9.22 of health care; 9.23 (3) a procedure to develop, compile, evaluate, and report 9.24 statistics relating to the cost of its operations, the pattern 9.25 of utilization of its services, the quality, availability and 9.26 accessibility of its services, and such other matters as may be 9.27 reasonably required by rule of the commissioner; and 9.28 (4) reasonable provisions for emergency and out-of-area 9.29 health care services. 9.30 (b) The commissioner of health shall provide the 9.31 certification, or notification that certification is not 9.32 forthcoming, to the commissioner within the time period 9.33 specified in subdivision 2. 9.34 Sec. 9. Minnesota Statutes 1998, section 62D.04, 9.35 subdivision 2, is amended to read: 9.36 Subd. 2. Within 90 days after the receipt of the 10.1 application for a certificate of authority, the commissionerof10.2healthshall determine whether or not the applicant meets the 10.3 requirements of this section. If the commissionerof health10.4 determines that the applicant meets the requirements of sections 10.5 62D.01 to 62D.30, the commissioner shall issue a certificate of 10.6 authority to the applicant. The commissioner shall not issue a 10.7 certificate without the certification by the commissioner of 10.8 health required by subdivision 1a. If the commissionerof10.9healthdetermines that the applicant is not qualified, the 10.10 commissioner shall so notify the applicant and shall specify the 10.11 reason or reasons for such disqualification. 10.12 Sec. 10. Minnesota Statutes 1998, section 62D.04, 10.13 subdivision 4, is amended to read: 10.14 Subd. 4. [CONTINUED COMPLIANCE.] Upon being granted a 10.15 certificate of authority to operate as a health maintenance 10.16 organization, the organization must continue to operate in 10.17 compliance with the standards set forth insubdivision 110.18 subdivisions 1 and 1a. Noncompliance may result in the 10.19 imposition of a fine or the suspension or revocation of the 10.20 certificate of authority, in accordance with sections 62D.15 to 10.21 62D.17. The commissioner of health shall inform the 10.22 commissioner of any failure to comply with subdivision 1a. 10.23 Sec. 11. Minnesota Statutes 1998, section 62D.05, 10.24 subdivision 6, is amended to read: 10.25 Subd. 6. [SUPPLEMENTAL BENEFITS.] (a) A health maintenance 10.26 organization may, as a supplemental benefit, provide coverage to 10.27 its enrollees for health care services and supplies received 10.28 from providers who are not employed by, under contract with, or 10.29 otherwise affiliated with the health maintenance organization. 10.30 Supplemental benefits may be provided if the following 10.31 conditions are met: 10.32 (1) a health maintenance organization desiring to offer 10.33 supplemental benefits must at all times comply with the 10.34 requirements of sections 62D.041 and 62D.042; 10.35 (2) a health maintenance organization offering supplemental 10.36 benefits must maintain an additional surplus in the first year 11.1 supplemental benefits are offered equal to the lesser of 11.2 $500,000 or 33 percent of the supplemental benefit expenses. At 11.3 the end of the second year supplemental benefits are offered, 11.4 the health maintenance organization must maintain an additional 11.5 surplus equal to the lesser of $1,000,000 or 33 percent of the 11.6 supplemental benefit expenses. At the end of the third year 11.7 benefits are offered and every year after that, the health 11.8 maintenance organization must maintain an additional surplus 11.9 equal to the greater of $1,000,000 or 33 percent of the 11.10 supplemental benefit expenses. When in the judgment of the 11.11 commissioner the health maintenance organization's surplus is 11.12 inadequate, the commissioner may require the health maintenance 11.13 organization to maintain additional surplus; 11.14 (3) claims relating to supplemental benefits must be 11.15 processed in accordance with the requirements of section 11.16 72A.201; and 11.17 (4) in marketing supplemental benefits, the health 11.18 maintenance organization shall fully disclose and describe to 11.19 enrollees and potential enrollees the nature and extent of the 11.20 supplemental coverage, and any claims filing and other 11.21 administrative responsibilities in regard to supplemental 11.22 benefits. 11.23 (b) The commissioner may, pursuant to chapter 14, adopt, 11.24 enforce, and administer rules relating to this subdivision, 11.25 including: rules insuring that these benefits are supplementary 11.26 and not substitutes for comprehensive health maintenance 11.27 services by addressing percentage of out-of-plan coverage; rules 11.28 relating to the establishment of necessary financial reserves; 11.29 rules relating to marketing practices; and other rules necessary 11.30 for the effective and efficient administration of this 11.31 subdivision. The commissioner, in adopting rules, shall give 11.32 consideration to existing laws and rules administered and 11.33 enforced by thedepartment of commercecommissioner relating to 11.34 health insurance plans. 11.35 Sec. 12. Minnesota Statutes 1998, section 62D.06, 11.36 subdivision 2, is amended to read: 12.1 Subd. 2. The governing body shall establish a mechanism to 12.2 afford the enrollees an opportunity to express their opinions in 12.3 matters of policy and operation through the establishment of 12.4 advisory panels, by the use of advisory referenda on major 12.5 policy decisions, or through the use of other mechanisms as may 12.6 be prescribed or permitted by the commissionerof health. 12.7 Sec. 13. Minnesota Statutes 1998, section 62D.07, 12.8 subdivision 2, is amended to read: 12.9 Subd. 2. No evidence of coverage or contract, or amendment 12.10 thereto shall be issued or delivered to any person in this state 12.11 until a copy of the form of the evidence of coverage or contract 12.12 or amendment thereto has been filed with the commissionerof12.13healthpursuant to section 62D.03 or 62D.08. 12.14 Sec. 14. Minnesota Statutes 1998, section 62D.07, 12.15 subdivision 3, is amended to read: 12.16 Subd. 3. Contracts and evidences of coverage shall contain: 12.17 (a) No provisions or statements which are unjust, unfair, 12.18 inequitable, misleading, deceptive, or which are untrue, 12.19 misleading, or deceptive as defined in section 62D.12, 12.20 subdivision 1; 12.21 (b) A clear, concise and complete statement of: 12.22 (1) the health care services and the insurance or other 12.23 benefits, if any, to which the enrollee is entitled under the 12.24 health maintenance contract; 12.25 (2) any exclusions or limitations on the services, kind of 12.26 services, benefits, or kind of benefits, to be provided, 12.27 including any deductible or copayment feature and requirements 12.28 for referrals, prior authorizations, and second opinions; 12.29 (3) where and in what manner information is available as to 12.30 how services, including emergency and out of area services, may 12.31 be obtained; 12.32 (4) the total amount of payment and copayment, if any, for 12.33 health care services and the indemnity or service benefits, if 12.34 any, which the enrollee is obligated to pay with respect to 12.35 individual contracts, or an indication whether the plan is 12.36 contributory or noncontributory with respect to group 13.1 certificates; and 13.2 (5) a description of the health maintenance organization's 13.3 method for resolving enrollee complaints and a statement 13.4 identifying the commissioner as an external source with whom 13.5 complaints may be registered; and 13.6 (c) On the cover page of the evidence of coverage and 13.7 contract, a clear and complete statement of enrollees' rights. 13.8 The statement must be in bold print and captioned "Important 13.9 Enrollee Information and Enrollee Bill of Rights" and must 13.10 include but not be limited to the following provisions in the 13.11 following language or in substantially similar language approved 13.12 in advance by the commissioner, except that paragraph (8) does 13.13 not apply to prepaid health plans providing coverage for 13.14 programs administered by the commissioner of human services: 13.15 ENROLLEE INFORMATION 13.16 (1) COVERED SERVICES: Services provided by (name of health 13.17 maintenance organization) will be covered only if services are 13.18 provided by participating (name of health maintenance 13.19 organization) providers or authorized by (name of health 13.20 maintenance organization). Your contract fully defines what 13.21 services are covered and describes procedures you must follow to 13.22 obtain coverage. 13.23 (2) PROVIDERS: Enrolling in (name of health maintenance 13.24 organization) does not guarantee services by a particular 13.25 provider on the list of providers. When a provider is no longer 13.26 part of (name of health maintenance organization), you must 13.27 choose among remaining (name of the health maintenance 13.28 organization) providers. 13.29 (3) REFERRALS: Certain services are covered only upon 13.30 referral. See section (section number) of your contract for 13.31 referral requirements. All referrals to non-(name of health 13.32 maintenance organization) providers and certain types of health 13.33 care providers must be authorized by (name of health maintenance 13.34 organization). 13.35 (4) EMERGENCY SERVICES: Emergency services from providers 13.36 who are not affiliated with (name of health maintenance 14.1 organization) will be covered only if proper procedures are 14.2 followed. Your contract explains the procedures and benefits 14.3 associated with emergency care from (name of health maintenance 14.4 organization) and non-(name of health maintenance organization) 14.5 providers. 14.6 (5) EXCLUSIONS: Certain services or medical supplies are 14.7 not covered. You should read the contract for a detailed 14.8 explanation of all exclusions. 14.9 (6) CONTINUATION: You may convert to an individual health 14.10 maintenance organization contract or continue coverage under 14.11 certain circumstances. These continuation and conversion rights 14.12 are explained fully in your contract. 14.13 (7) CANCELLATION: Your coverage may be canceled by you or 14.14 (name of health maintenance organization) only under certain 14.15 conditions. Your contract describes all reasons for 14.16 cancellation of coverage. 14.17 (8) NEWBORN COVERAGE: If your health plan provides for 14.18 dependent coverage, a newborn infant is covered from birth, but 14.19 only if services are provided by participating (name of health 14.20 maintenance organization) providers or authorized by (name of 14.21 health maintenance organization). Certain services are covered 14.22 only upon referral. (Name of health maintenance organization) 14.23 will not automatically know of the infant's birth or that you 14.24 would like coverage under your plan. You should notify (name of 14.25 health maintenance organization) of the infant's birth and that 14.26 you would like coverage. If your contract requires an 14.27 additional premium for each dependent, (name of health 14.28 maintenance organization) is entitled to all premiums due from 14.29 the time of the infant's birth until the time you notify (name 14.30 of health maintenance organization) of the birth. (Name of 14.31 health maintenance organization) may withhold payment of any 14.32 health benefits for the newborn infant until any premiums you 14.33 owe are paid. 14.34 (9) PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT: Enrolling in 14.35 (name of health maintenance organization) does not guarantee 14.36 that any particular prescription drug will be available nor that 15.1 any particular piece of medical equipment will be available, 15.2 even if the drug or equipment is available at the start of the 15.3 contract year. 15.4 ENROLLEE BILL OF RIGHTS 15.5 (1) Enrollees have the right to available and accessible 15.6 services including emergency services, as defined in your 15.7 contract, 24 hours a day and seven days a week; 15.8 (2) Enrollees have the right to be informed of health 15.9 problems, and to receive information regarding treatment 15.10 alternatives and risks which is sufficient to assure informed 15.11 choice; 15.12 (3) Enrollees have the right to refuse treatment, and the 15.13 right to privacy of medical and financial records maintained by 15.14 the health maintenance organization and its health care 15.15 providers, in accordance with existing law; 15.16 (4) Enrollees have the right to file a complaint with the 15.17 health maintenance organization and the commissioner ofhealth15.18 commerce and the right to initiate a legal proceeding when 15.19 experiencing a problem with the health maintenance organization 15.20 or its health care providers; 15.21 (5) Enrollees have the right to a grace period of 31 days 15.22 for the payment of each premium for an individual health 15.23 maintenance contract falling due after the first premium during 15.24 which period the contract shall continue in force; 15.25 (6) Medicare enrollees have the right to voluntarily 15.26 disenroll from the health maintenance organization and the right 15.27 not to be requested or encouraged to disenroll except in 15.28 circumstances specified in federal law; and 15.29 (7) Medicare enrollees have the right to a clear 15.30 description of nursing home and home care benefits covered by 15.31 the health maintenance organization. 15.32 Sec. 15. Minnesota Statutes 1998, section 62D.07, 15.33 subdivision 10, is amended to read: 15.34 Subd. 10. An individual health maintenance organization 15.35 contract and an evidence of coverage must contain a department 15.36 ofhealthcommerce telephone number that the enrollee can call 16.1 to register a complaint about a health maintenance organization. 16.2 Sec. 16. Minnesota Statutes 1998, section 62D.08, 16.3 subdivision 1, is amended to read: 16.4 Subdivision 1. A health maintenance organization shall, 16.5 unless otherwise provided for by rules adopted by the 16.6 commissionerof health, file notice with the commissionerof16.7healthprior to any modification of the operations or documents 16.8 described in the information submitted under clauses (a), (b), 16.9 (e), (f), (g), (i), (j), (l), (m), (n), (o), (p), (q), (r), (s), 16.10 and (t) of section 62D.03, subdivision 4. If the modification 16.11 involves the operations or documents described in the 16.12 information submitted under section 62D.03, subdivision 4, 16.13 clause (o), the notice of modification must be filed with the 16.14 commissioner of health at the same time it is filed with the 16.15 commissioner. The commissioner of health shall provide the 16.16 commissioner with a recommendation on the approval or 16.17 disapproval of the modifications within 60 days of the filing. 16.18 If the commissionerof healthdoes not disapprove of the filing 16.19 within 60 days, it shall be deemed approved and may be 16.20 implemented by the health maintenance organization. 16.21 Sec. 17. Minnesota Statutes 1998, section 62D.08, 16.22 subdivision 2, is amended to read: 16.23 Subd. 2. Every health maintenance organization shall 16.24 annually, on or before April 1, file a verified report with the 16.25 commissionerof healthand with the commissioner of health, 16.26 covering the preceding calendar year. However, utilization data 16.27 required under subdivision 3, clause (c), shall be filed on or 16.28 before July 1. 16.29 Sec. 18. Minnesota Statutes 1998, section 62D.08, 16.30 subdivision 3, is amended to read: 16.31 Subd. 3. Such report shall be on forms prescribed by the 16.32 commissionerof health, and shall include: 16.33 (a) A financial statement of the organization, including 16.34 its balance sheet and receipts and disbursements for the 16.35 preceding year certified by an independent certified public 16.36 accountant, reflecting at least (1) all prepayment and other 17.1 payments received for health care services rendered, (2) 17.2 expenditures to all providers, by classes or groups of 17.3 providers, and insurance companies or nonprofit health service 17.4 plan corporations engaged to fulfill obligations arising out of 17.5 the health maintenance contract, (3) expenditures for capital 17.6 improvements, or additions thereto, including but not limited to 17.7 construction, renovation or purchase of facilities and capital 17.8 equipment, and (4) a supplementary statement of assets, 17.9 liabilities, premium revenue, and expenditures for risk sharing 17.10 business under section 62D.04, subdivision 1, on forms 17.11 prescribed by the commissioner; 17.12 (b) The number of new enrollees enrolled during the year, 17.13 the number of group enrollees and the number of individual 17.14 enrollees as of the end of the year and the number of enrollees 17.15 terminated during the year; 17.16 (c) A summary of information compiled pursuant to section 17.17 62D.04,subdivision 1, clause (c)subdivision 1a, paragraph (a), 17.18 clause (3), in such form as may be required by the 17.19 commissionerof health; 17.20 (d) A report of the names and addresses of all persons set 17.21 forth in section 62D.03, subdivision 4, clause (c), who were 17.22 associated with the health maintenance organization or the major 17.23 participating entity during the preceding year, and the amount 17.24 of wages, expense reimbursements, or other payments to such 17.25 individuals for services to the health maintenance organization 17.26 or the major participating entity, as those services relate to 17.27 the health maintenance organization, including a full disclosure 17.28 of all financial arrangements during the preceding year required 17.29 to be disclosed pursuant to section 62D.03, subdivision 4, 17.30 clause (d); 17.31 (e) A separate report addressing health maintenance 17.32 contracts sold to individuals covered by Medicare, title XVIII 17.33 of the Social Security Act, as amended, including the 17.34 information required under section 62D.30, subdivision 6; and 17.35 (f) Such other information relating to the performance of 17.36 the health maintenance organization as is reasonably necessary 18.1 to enable the commissionerof healthto carry out the duties 18.2 under sections 62D.01 to 62D.30. 18.3 Sec. 19. Minnesota Statutes 1998, section 62D.08, 18.4 subdivision 4, is amended to read: 18.5 Subd. 4. Any health maintenance organization which fails 18.6 to file a verified report with the commissioner and with the 18.7 commissioner of health on or before April 1 of the year due 18.8 shall be subject to the levy of a fine up to $500 for each day 18.9 the report is past due. This failure will serve as a basis for 18.10 other disciplinary action against the organization, including 18.11 suspension or revocation, in accordance with sections 62D.15 to 18.12 62D.17 and chapter 45. The commissioner may grant an extension 18.13 of the reporting deadline upon good cause shown by the health 18.14 maintenance organization. Any fine levied or disciplinary 18.15 action taken against the organization under this subdivision is 18.16 subject to the contested case and judicial review provisions of 18.17 sections 14.57 to 14.69. 18.18 Sec. 20. Minnesota Statutes 1998, section 62D.08, 18.19 subdivision 5, is amended to read: 18.20 Subd. 5. Every health maintenance organization shall 18.21 inform the commissioner of any change in the information 18.22 described in section 62D.03, subdivision 4, clause (e), 18.23 including any change in address, any modification of the 18.24 duration of any contract or agreement, and any addition to the 18.25 list of participating entities, within ten working days of the 18.26 notification of the change. Any cancellation or discontinuance 18.27 of any contract or agreement listed in section 62D.03, 18.28 subdivision 4, clause (e), or listed subsequently in accordance 18.29 with this subdivision, shall be reported to the commissioner 120 18.30 days before the effective date. When the health maintenance 18.31 organization terminates a provider for cause, death, disability, 18.32 or loss of license, the health maintenance organization must 18.33 notify the commissioner within three working days of the date 18.34 the health maintenance organization sends out or receives the 18.35 notice of cancellation, discontinuance, or termination. Any 18.36 health maintenance organization which fails to notify the 19.1 commissioner within the time periods prescribed in this 19.2 subdivision shall be subject to the levy of a fine up to $200 19.3 per contract for each day the notice is past due, accruing up to 19.4 the date the organization notifies the commissioner of the 19.5 cancellation or discontinuance. Any fine levied under this 19.6 subdivision is subject to the contested case and judicial review 19.7 provisions of chapter 14. The levy of a fine does not preclude 19.8 the commissioner from using other penalties described in 19.9 sections 62D.15 to 62D.17 and chapter 45. 19.10 Sec. 21. Minnesota Statutes 1998, section 62D.09, 19.11 subdivision 1, is amended to read: 19.12 Subdivision 1. (a) Any written marketing materials which 19.13 may be directed toward potential enrollees and which include a 19.14 detailed description of benefits provided by the health 19.15 maintenance organization shall include a statement of enrollee 19.16 information and rights as described in section 62D.07, 19.17 subdivision 3, paragraphs (b) and (c). Prior to any oral 19.18 marketing presentation, the agent marketing the plan must inform 19.19 the potential enrollees that any complaints concerning the 19.20 material presented should be directed to the health maintenance 19.21 organization, the commissionerof health, or, if applicable, the 19.22 employer. 19.23 (b) Detailed marketing materials must affirmatively 19.24 disclose all exclusions and limitations in the organization's 19.25 services or kinds of services offered to the contracting party, 19.26 including but not limited to the following types of exclusions 19.27 and limitations: 19.28 (1) health care services not provided; 19.29 (2) health care services requiring copayments or 19.30 deductibles paid by enrollees; 19.31 (3) the fact that access to health care services does not 19.32 guarantee access to a particular provider type; and 19.33 (4) health care services that are or may be provided only 19.34 by referral of a physician. 19.35 (c) No marketing materials may lead consumers to believe 19.36 that all health care needs will be covered. All marketing 20.1 materials must alert consumers to possible uncovered expenses 20.2 with the following language in bold print: "THIS HEALTH CARE 20.3 PLAN MAY NOT COVER ALL YOUR HEALTH CARE EXPENSES; READ YOUR 20.4 CONTRACT CAREFULLY TO DETERMINE WHICH EXPENSES ARE COVERED." 20.5 Immediately following the disclosure required under paragraph 20.6 (b), clause (3), consumers must be given a telephone number to 20.7 use to contact the health maintenance organization for specific 20.8 information about access to provider types. 20.9 (d) The disclosures required in paragraphs (b) and (c) are 20.10 not required on billboards or image, and name identification 20.11 advertisement. 20.12 Sec. 22. Minnesota Statutes 1998, section 62D.09, 20.13 subdivision 8, is amended to read: 20.14 Subd. 8. Each health maintenance organization shall issue 20.15 a membership card to its enrollees. The membership card must: 20.16 (1) identify the health maintenance organization; 20.17 (2) include the name, address, and telephone number to call 20.18 if the enrollee has a complaint; 20.19 (3) include the telephone number to call or the instruction 20.20 on how to receive authorization for emergency care; and 20.21 (4) include one of the following: 20.22 (i) the telephone number to call to appeal to or file a 20.23 complaint with the commissionerof health; or 20.24 (ii) for persons enrolled under section 256B.69, 256D.03, 20.25 or 256L.12, the telephone number to call to file a complaint 20.26 with the ombudsperson designated by the commissioner of human 20.27 services under section 256B.69 and the address to appeal to the 20.28 commissioner of human services. The ombudsperson shall annually 20.29 provide the commissionerof healthwith a summary of complaints 20.30 and actions taken. 20.31 Sec. 23. Minnesota Statutes 1998, section 62D.10, 20.32 subdivision 4, is amended to read: 20.33 Subd. 4. A health plan may apply to the commissionerof20.34healthfor a waiver of the requirements of this section or for 20.35 authorization to impose such underwriting restrictions upon open 20.36 enrollment as are necessary (a) to preserve its financial 21.1 stability, (b) to prevent excessive adverse selection by 21.2 prospective enrollees, or (c) to avoid unreasonably high or 21.3 unmarketable charges for enrollee coverage for health care 21.4 services. The commissionerof healthupon a showing of good 21.5 cause, shall approve or upon failure to show good cause shall 21.6 deny such application within 30 days of the receipt thereof from 21.7 the health plan. The commissionerof healthmay, in accordance 21.8 with chapter 14, promulgate rules to implement this section. 21.9 Sec. 24. Minnesota Statutes 1998, section 62D.11, 21.10 subdivision 1b, is amended to read: 21.11 Subd. 1b. [EXPEDITED RESOLUTION OF COMPLAINTS ABOUT 21.12 MEDICALLY URGENT SERVICES.] In addition to any remedy contained 21.13 in subdivision 1a, when a complaint involves a dispute about a 21.14 health maintenance organization's coverage of a medically urgent 21.15 service, the commissioner or the commissioner of health may also 21.16 order the health maintenance organization to use an expedited 21.17 system to process the complaint. 21.18 Sec. 25. Minnesota Statutes 1998, section 62D.11, 21.19 subdivision 2, is amended to read: 21.20 Subd. 2. The health maintenance organization shall 21.21 maintain a record of each written complaint filed with it for 21.22 five years and the commissionerof healthand the commissioner 21.23 of health shall have access to the records. 21.24 Sec. 26. Minnesota Statutes 1998, section 62D.11, 21.25 subdivision 3, is amended to read: 21.26 Subd. 3. [DENIAL OF COVERAGE.] Within a reasonable time 21.27 after receiving an enrollee's written or oral communication to 21.28 the health maintenance organization concerning a denial of 21.29 coverage or inadequacy of services, the health maintenance 21.30 organization shall provide the enrollee with a written statement 21.31 of the reason for the denial of coverage, and a statement 21.32 approved by the commissionerof healthwhich explains the health 21.33 maintenance organization complaint procedures, and in the case 21.34 of Medicare enrollees, which also explains Medicare appeal 21.35 procedures. 21.36 Sec. 27. Minnesota Statutes 1998, section 62D.11, is 22.1 amended by adding a subdivision to read: 22.2 Subd. 5. [REFERRAL TO COMMISSIONER OF HEALTH.] (a) The 22.3 commissioner shall determine whether a complaint relates 22.4 primarily to quality of care. The commissioner shall refer such 22.5 complaints to the commissioner of health for information, 22.6 recommendation, investigation, or resolution. 22.7 (b) All investigation, examination, rulemaking action, 22.8 penalty assessment, and enforcement authority under this chapter 22.9 is available to the commissioner of health on matters related to 22.10 the quality of care. 22.11 Sec. 28. Minnesota Statutes 1998, section 62D.12, 22.12 subdivision 1, is amended to read: 22.13 Subdivision 1. No health maintenance organization or 22.14 representative thereof may cause or knowingly permit the use of 22.15 advertising or solicitation which is untrue or misleading, or 22.16 any form of evidence of coverage which is deceptive. Each 22.17 health maintenance organization shall be subject to sections 22.18 72A.17 to 72A.32, relating to the regulation of trade practices, 22.19 except(a)to the extent that the nature of a health maintenance 22.20 organization renders such sections clearly inappropriateand (b)22.21that enforcement shall be by the commissioner of health and not22.22by the commissioner of commerce. Every health maintenance 22.23 organization shall be subject to sections 8.31 and 325F.69. 22.24 Sec. 29. Minnesota Statutes 1998, section 62D.12, 22.25 subdivision 2, is amended to read: 22.26 Subd. 2. No health maintenance organization may cancel or 22.27 fail to renew the coverage of an enrollee except for (a) failure 22.28 to pay the charge for health care coverage; (b) termination of 22.29 the health care plan; (c) termination of the group plan; (d) 22.30 enrollee moving out of the area served, subject to section 22.31 62A.17, subdivisions 1 and 6, and section 62D.104; (e) enrollee 22.32 moving out of an eligible group, subject to section 62A.17, 22.33 subdivisions 1 and 6, and section 62D.104; (f) failure to make 22.34 copayments required by the health care plan; or (g) other 22.35 reasons established in rules promulgated by the commissionerof22.36health. 23.1 Sec. 30. Minnesota Statutes 1998, section 62D.12, 23.2 subdivision 9, is amended to read: 23.3 Subd. 9. All net earnings of the health maintenance 23.4 organization shall be devoted to the nonprofit purposes of the 23.5 health maintenance organization in providing comprehensive 23.6 health care. No health maintenance organization shall provide 23.7 for the payment, whether directly or indirectly, of any part of 23.8 its net earnings, to any person as a dividend or rebate; 23.9 provided, however, that health maintenance organizations may 23.10 make payments to providers or other persons based upon the 23.11 efficient provision of services or as incentives to provide 23.12 quality care. The commissionerof healthshall, pursuant to 23.13 sections 62D.01 to 62D.30, revoke the certificate of authority 23.14 of any health maintenance organization in violation of this 23.15 subdivision. 23.16 Sec. 31. Minnesota Statutes 1998, section 62D.121, 23.17 subdivision 3a, is amended to read: 23.18 Subd. 3a. If the replacement coverage is health 23.19 maintenance organization coverage, as explained in subdivisions 23.20 2 and 2a, the fee shall not exceed 125 percent of the cost of 23.21 the average fee charged by health maintenance organizations for 23.22 a similar health plan. The commissionerof health willshall 23.23 determine the average cost of the plan on the basis of 23.24 information provided annually by the health maintenance 23.25 organizations concerning the rates charged by the health 23.26 maintenance organizations for the plans offered. Fees or 23.27 premiums charged under this section must be actuarially 23.28 justified. 23.29 Sec. 32. Minnesota Statutes 1998, section 62D.121, 23.30 subdivision 7, is amended to read: 23.31 Subd. 7. [GEOGRAPHIC ACCESSIBILITY.] If the 23.32 commissioner of health determines that there are not enough 23.33 providers to assure that enrollees have accessible health 23.34 services available in a geographic service area, the 23.35 commissioner of health shall institute a plan of corrective 23.36 action that shall be followed by the health maintenance 24.1 organization. Such a plan may include but not be limited to 24.2 requiring the health maintenance organization to make payments 24.3 to nonparticipating providers for health services for enrollees, 24.4 requiring the health maintenance organization to discontinue 24.5 accepting new enrollees in that service area, and requiring the 24.6 health maintenance organization to reduce its geographic service 24.7 area. If a nonparticipating provider has been a participating 24.8 provider with the health maintenance organization within the 24.9 last year, any payments made under this section must not exceed 24.10 the payment level of the previous contract unless the 24.11 commissioner of health determines that without adjusting 24.12 payments the health maintenance organization will be unable to 24.13 meet the health care needs of enrollees in the area. 24.14 Sec. 33. Minnesota Statutes 1998, section 62D.14, 24.15 subdivision 1, is amended to read: 24.16 Subdivision 1. The commissionerof healthmay make an 24.17 examination of the affairs of any health maintenance 24.18 organization and its contracts, agreements, or other 24.19 arrangements with any participating entity as often as the 24.20 commissionerof healthdeems necessary for the protection of the 24.21 interests of the people of this state, but not less frequently 24.22 than once every three years. Examinations of participating 24.23 entities pursuant to this subdivision shall be limited to their 24.24 dealings with the health maintenance organization and its 24.25 enrollees, except that examinations of major participating 24.26 entities may include inspection of the entity's financial 24.27 statements kept in the ordinary course of business. The 24.28 commissioner may require major participating entities to submit 24.29 the financial statements directly to the commissioner. 24.30 Financial statements of major participating entities are subject 24.31 to the provisions of section 13.37, subdivision 1, clause (b), 24.32 upon request of the major participating entity or the health 24.33 maintenance organization with which it contracts. 24.34 Sec. 34. Minnesota Statutes 1998, section 62D.14, 24.35 subdivision 3, is amended to read: 24.36 Subd. 3. In order to accomplish the duties under this 25.1 section with respect to the dealings of the participating 25.2 entities with the health maintenance organization, the 25.3 commissionerof health shall havehas the right to: 25.4 (a) inspect or otherwise evaluate the quality, 25.5 appropriateness, and timeliness of services performed, or 25.6 arrange with the commissioner of health for the commissioner of 25.7 health to do so; 25.8 (b) audit and inspect any books and records of a health 25.9 maintenance organization and a participating entity which 25.10 pertain to services performed and determinations of amounts 25.11 payable under such contract; 25.12 (c) require persons or organizations under examination to 25.13 be deposed and to answer interrogatories, regardless of whether 25.14 an administrative hearing or other civil proceeding has been or 25.15 will be initiated; and 25.16 (d) employ site visits, public hearings, or any other 25.17 procedures considered appropriate to obtain the information 25.18 necessary to determine the issues. 25.19 Sec. 35. Minnesota Statutes 1998, section 62D.14, 25.20 subdivision 4, is amended to read: 25.21 Subd. 4. Any data or information pertaining to the 25.22 diagnosis, treatment, or health of any enrollee, or any 25.23 application obtained from any person, shall be private as 25.24 defined in chapter 13 and shall not be disclosed to any person 25.25 except (a) to the extent necessary to carry out the purposes of 25.26 sections 62D.01 to 62D.30, the commissioner and the commissioner 25.27 of health and a designee shall have access to the above data or 25.28 information but the data removed from the health maintenance 25.29 organization or participating entity shall not identify any 25.30 particular patient or client by name or contain any other unique 25.31 personal identifier; (b) upon the express consent of the 25.32 enrollee or applicant; (c) pursuant to statute or court order 25.33 for the production of evidence or the discovery thereof; or (d) 25.34 in the event of claim or litigation between such person and the 25.35 provider or health maintenance organization wherein such data or 25.36 information is pertinent. In any case involving a suspected 26.1 violation of a law applicable to health maintenance 26.2 organizations in which access to health data maintained by the 26.3 health maintenance organization or participating entity is 26.4 necessary, the commissioner and the commissioner of health and 26.5 agents, while maintaining the privacy rights of individuals and 26.6 families, shall be permitted to obtain data that identifies any 26.7 particular patient or client by name. A health maintenance 26.8 organization shall be entitled to claim any statutory privileges 26.9 against such disclosure which the provider who furnished such 26.10 information to the health maintenance organization is entitled 26.11 to claim. 26.12 Sec. 36. Minnesota Statutes 1998, section 62D.14, 26.13 subdivision 5, is amended to read: 26.14 Subd. 5. The commissionerof health shalland the 26.15 commissioner of health have the power to administer oaths to and 26.16 examine witnesses, and to issue subpoenas. 26.17 Sec. 37. Minnesota Statutes 1998, section 62D.14, 26.18 subdivision 6, is amended to read: 26.19 Subd. 6. Reasonable expenses of examinations under this 26.20 section shall be assessed by the commissionerof healthagainst 26.21 the organization being examined, and shall be remitted to the 26.22 commissionerof healthfor deposit in the general fund of the 26.23 state treasury. 26.24 Sec. 38. Minnesota Statutes 1998, section 62D.15, 26.25 subdivision 1, is amended to read: 26.26 Subdivision 1. [SUSPENSION OR REVOCATION.] (a) The 26.27 commissionerof healthmay suspend or revoke any certificate of 26.28 authority issued to a health maintenance organization under 26.29 sections 62D.01 to 62D.30 if the commissioner finds that: 26.30(a)(1) The health maintenance organization is operating 26.31 significantly in contravention of its basic organizational 26.32 document, its health maintenance contract, or in a manner 26.33 contrary to that described in and reasonably inferred from any 26.34 other information submitted under section 62D.03, unless 26.35 amendments to such submissions have been filed with and approved 26.36 by the commissionerof health; 27.1(b)(2) The health maintenance organization issues 27.2 evidences of coverage which do not comply with the requirements 27.3 of section 62D.07; 27.4(c)(3) The health maintenance organization is unable to 27.5 fulfill its obligations to furnish comprehensive health 27.6 maintenance services as required under its health maintenance 27.7 contract; 27.8(d)(4) The health maintenance organization is no longer 27.9 financially responsible and may reasonably be expected to be 27.10 unable to meet its obligations to enrollees or prospective 27.11 enrollees; 27.12(e)(5) The health maintenance organization has failed to 27.13 implement a mechanism affording the enrollees an opportunity to 27.14 participate in matters of policy and operation under section 27.15 62D.06; 27.16(f)(6) The health maintenance organization has failed to 27.17 implement the complaint system required by section 62D.11 in a 27.18 manner designed to reasonably resolve valid complaints; 27.19(g)(7) The health maintenance organization, or any person 27.20 acting with its sanction, has advertised or merchandised its 27.21 services in an untrue, misrepresentative, misleading, deceptive, 27.22 or unfair manner; 27.23(h)(8) The continued operation of the health maintenance 27.24 organization would be hazardous to its enrollees; or 27.25(i)(9) The health maintenance organization has otherwise 27.26 failed to substantially comply with sections 62D.01 to 62D.30 or 27.27 with any other statute or administrative rule applicable to 27.28 health maintenance organizations, or has submitted false 27.29 information in any report required hereunder. 27.30 (b) The commissioner of health may by order suspend or 27.31 revoke the certificate of authority of a health maintenance 27.32 organization when the commissioner of health finds failure to 27.33 comply with section 62D.04, subdivision 1a, or any other area of 27.34 responsibility assigned by statute or rule to the commissioner 27.35 of health. The commissioner of health shall notify the 27.36 commissioner of any action taken under this paragraph. 28.1 Sec. 39. Minnesota Statutes 1998, section 62D.15, 28.2 subdivision 4, is amended to read: 28.3 Subd. 4. When the certificate of authority of a health 28.4 maintenance organization is revoked, the organization shall 28.5 proceed, immediately following the effective date of the order 28.6 of revocation, to wind up its affairs, and shall conduct no 28.7 further business except as may be essential to the orderly 28.8 conclusion of the affairs of the organization. It shall engage 28.9 in no further advertising or solicitation whatsoever. The 28.10 commissionerof healthmay, by written order, permit further 28.11 operation of the organization as the commissioner may find to be 28.12 in the best interest of enrollees, to the end that enrollees 28.13 will be afforded the greatest practical opportunity to obtain 28.14 continuing health care coverage. 28.15 Sec. 40. Minnesota Statutes 1998, section 62D.16, 28.16 subdivision 1, is amended to read: 28.17 Subdivision 1. When the commissionerof healthhas cause 28.18 to believe that grounds for the denial, suspension or revocation 28.19 of a certificate of authority exists, the commissioner shall 28.20 notify the health maintenance organization in writing 28.21 specifically stating the grounds for denial, suspension or 28.22 revocation and fixing a time of at least 20 days thereafter for 28.23 a hearing on the matter, except in summary proceedings as 28.24 provided in section 62D.18. 28.25 Sec. 41. Minnesota Statutes 1998, section 62D.16, 28.26 subdivision 2, is amended to read: 28.27 Subd. 2. After such hearing, or upon the failure of the 28.28 health maintenance organization to appear at the hearing, the 28.29 commissionerof healthshall take action as is deemed advisable 28.30 and shall issue written findings which shall be mailed to the 28.31 health maintenance organization. The action of the commissioner 28.32of healthshall be subject to judicial review pursuant to 28.33 chapter 14. 28.34 Sec. 42. Minnesota Statutes 1998, section 62D.17, 28.35 subdivision 1, is amended to read: 28.36 Subdivision 1. The commissionerof healthmay, for any 29.1 violation of statute or rule applicable to a health maintenance 29.2 organization, or in lieu of suspension or revocation of a 29.3 certificate of authority under section 62D.15, levy an 29.4 administrative penalty in an amount up to $25,000 for each 29.5 violation. In the case of contracts or agreements made pursuant 29.6 to section 62D.05, subdivisions 2 to 4, each contract or 29.7 agreement entered into or implemented in a manner which violates 29.8 sections 62D.01 to 62D.30 shall be considered a separate 29.9 violation. In determining the level of an administrative 29.10 penalty, the commissioner shall consider the following factors: 29.11 (1) the number of enrollees affected by the violation; 29.12 (2) the effect of the violation on enrollees' health and 29.13 access to health services; 29.14 (3) if only one enrollee is affected, the effect of the 29.15 violation on that enrollee's health; 29.16 (4) whether the violation is an isolated incident or part 29.17 of a pattern of violations;and29.18 (5) the economic benefits derived by the health maintenance 29.19 organization or a participating provider by virtue of the 29.20 violation; and 29.21 (6) any recommendation made by the commissioner of health. 29.22 Reasonable notice in writing to the health maintenance 29.23 organization shall be given of the intent to levy the penalty 29.24 and the reasons therefor, and the health maintenance 29.25 organization may have 15 days within which to file a written 29.26 request for an administrative hearing and review of the 29.27commissioner of health'scommissioner's determination. Such 29.28 administrative hearing shall be subject to judicial review 29.29 pursuant to chapter 14. 29.30 Sec. 43. Minnesota Statutes 1998, section 62D.17, 29.31 subdivision 3, is amended to read: 29.32 Subd. 3. (a) If the commissionerof healthshall, for any 29.33 reason, have cause to believe that any violation of sections 29.34 62D.01 to 62D.30 has occurred or is threatened, the commissioner 29.35of healthmay, before commencing action under sections 62D.15 29.36 and 62D.16, and subdivision 1, give notice to the health 30.1 maintenance organization and to the representatives, or other 30.2 persons who appear to be involved in such suspected violation, 30.3 to arrange a voluntary conference with the alleged violators or 30.4 their authorized representatives for the purpose of attempting 30.5 to ascertain the facts relating to such suspected violation and, 30.6 in the event it appears that any violation has occurred or is 30.7 threatened, to arrive at an adequate and effective means of 30.8 correcting or preventing such violation. 30.9 (b) Proceedings under this subdivision shall not be 30.10 governed by any formal procedural requirements, and may be 30.11 conducted in such manner as the commissionerof healthmay deem 30.12 appropriate under the circumstances. 30.13 Sec. 44. Minnesota Statutes 1998, section 62D.17, 30.14 subdivision 4, is amended to read: 30.15 Subd. 4. (a) The commissionerof healthmay issue an order 30.16 directing a health maintenance organization or a representative 30.17 of a health maintenance organization to cease and desist from 30.18 engaging in any act or practice in violation of the provisions 30.19 of sections 62D.01 to 62D.30. 30.20 (1) The cease and desist order may direct a health 30.21 maintenance organization to pay for or provide a service when 30.22 that service is required by statute or rule to be provided. 30.23 (2) Thecommissioner may issue acease and desist order 30.24directingmay direct a health maintenance organization to pay 30.25 for a service that is required by statute or rule to be 30.26 provided, only if there is a demonstrable and irreparable harm 30.27 to the public or an enrollee. 30.28 (3) If the cease and desist order involves a dispute over 30.29 the medical necessity of a procedure based on its experimental 30.30 nature, the commissioner may issue a cease and desist order only 30.31 if the following conditions are met: 30.32 (i) the commissioner has consulted with appropriate and 30.33 identified experts; 30.34 (ii) the commissioner has reviewed relevant scientific and 30.35 medical literature; and 30.36 (iii) the commissioner has considered all other relevant 31.1 factors including whether final approval of the technology or 31.2 procedure has been granted by the appropriate government agency; 31.3 the availability of scientific evidence concerning the effect of 31.4 the technology or procedure on health outcomes; the availability 31.5 of scientific evidence that the technology or procedure is as 31.6 beneficial as established alternatives; and the availability of 31.7 evidence of benefit or improvement without the technology or 31.8 procedure. 31.9 (b) Within 20 days after service of the order to cease and 31.10 desist, the respondent may request a hearing on the question of 31.11 whether acts or practices in violation of sections 62D.01 to 31.12 62D.30 have occurred. Such hearings shall be subject to 31.13 judicial review as provided by chapter 14. 31.14 If the acts or practices involve violation of the reporting 31.15 requirements of section 62D.08, or if the commissioner has 31.16 ordered the rehabilitation, liquidation, or conservation of the 31.17 health maintenance organization in accordance with section 31.18 62D.18, the health maintenance organization may request an 31.19 expedited hearing on the matter. The hearing shall be held 31.20 within 15 days of the request. Within ten days thereafter, an 31.21 administrative law judge shall issue a recommendation on the 31.22 matter. The commissioner shall make a final determination on 31.23 the matter within ten days of receipt of the administrative law 31.24 judge's recommendation. 31.25When a request for a stay accompanies the hearing request,31.26the matter shall be referred to the office of administrative31.27hearings within three working days of receipt of the request.31.28Within ten days thereafter, an administrative law judge shall31.29issue a recommendation to grant or deny the stay. The31.30commissioner shall grant or deny the stay within five days of31.31receipt of the administrative law judge's recommendation.31.32To the extent the acts or practices alleged do not involve31.33(1) violations of section 62D.08; (2) violations which may31.34result in the financial insolvency of the health maintenance31.35organization; (3) violations which threaten the life and health31.36of enrollees; (4) violations which affect whole classes of32.1enrollees; or (5) violations of benefits or service requirements32.2mandated by law; if a timely request for a hearing is made, the32.3cease and desist order shall be stayed for a period of 90 days32.4from the date the hearing is requested or until a final32.5determination is made on the order, whichever is earlier.32.6During this stay, the respondent may show cause why the order32.7should not become effective upon the expiration of the stay.32.8Arguments on this issue shall be made through briefs filed with32.9the administrative law judge no later than ten days prior to the32.10expiration of the stay.32.11 Sec. 45. Minnesota Statutes 1998, section 62D.17, 32.12 subdivision 5, is amended to read: 32.13 Subd. 5. In the event of noncompliance with a cease and 32.14 desist order issued pursuant to subdivision 4, the commissioner 32.15of healthmay institute a proceeding to obtain injunctive relief 32.16 or other appropriate relief in Ramsey county district court. 32.17 Sec. 46. Minnesota Statutes 1998, section 62D.18, 32.18 subdivision 1, is amended to read: 32.19 Subdivision 1. [COMMISSIONER OF HEALTH;COURT ORDER.] The 32.20 commissionerof healthmay apply by verified petition to the 32.21 district court of Ramsey county or the county in which the 32.22 principal office of the health maintenance organization is 32.23 located for an order directing the commissionerof healthto 32.24 rehabilitate or liquidate a health maintenance organization. 32.25 The rehabilitation or liquidation of a health maintenance 32.26 organization shall be conducted under the supervision of the 32.27 commissionerof healthunder the procedures, and with the powers 32.28 granted to a rehabilitator or liquidator, in chapter 60B, except 32.29 to the extent that the nature of health maintenance 32.30 organizations renders the procedures or powers clearly 32.31 inappropriate and as provided in this subdivision or in chapter 32.32 60B. A health maintenance organization shall be considered an 32.33 insurance company for the purposes of rehabilitation or 32.34 liquidation as provided in subdivisions 4, 6, and 7. 32.35 Sec. 47. Minnesota Statutes 1998, section 62D.18, 32.36 subdivision 7, is amended to read: 33.1 Subd. 7. [EXAMINATION ACCOUNT.] The commissionerof health33.2 shall assess against a health maintenance organization not yet 33.3 in rehabilitation or liquidation a fee sufficient to cover the 33.4 costs of a special examination. The fee must be deposited in an 33.5 examination account. Money in the account is appropriated to 33.6 the commissionerof healthto pay for the examinations. If the 33.7 money in the account is insufficient to pay the initial costs of 33.8 examinations, the commissioner may use other money appropriated 33.9 to the commissioner, provided the other appropriation is 33.10 reimbursed from the examination account when it contains 33.11 sufficient money. Money from the examination account must be 33.12 used to pay per diem salaries and expenses of special examiners, 33.13 including meals, lodging, laundry, transportation, and mileage. 33.14 The salary of regular employees of thehealthcommerce 33.15 department must not be paid out of the account. 33.16 Sec. 48. Minnesota Statutes 1998, section 62D.19, is 33.17 amended to read: 33.18 62D.19 [UNREASONABLE EXPENSES.] 33.19 No health maintenance organization shall incur or pay for 33.20 any expense of any nature which is unreasonably high in relation 33.21 to the value of the service or goods provided. The commissioner 33.22of healthshall implement and enforce this section by rules 33.23 adopted under this section. 33.24 In an effort to achieve the stated purposes of sections 33.25 62D.01 to 62D.30; in order to safeguard the underlying nonprofit 33.26 status of health maintenance organizations; and to ensure that 33.27 the payment of health maintenance organization money to major 33.28 participating entities results in a corresponding benefit to the 33.29 health maintenance organization and its enrollees, when 33.30 determining whether an organization has incurred an unreasonable 33.31 expense in relation to a major participating entity, due 33.32 consideration shall be given to, in addition to any other 33.33 appropriate factors, whether the officers and trustees of the 33.34 health maintenance organization have acted with good faith and 33.35 in the best interests of the health maintenance organization in 33.36 entering into, and performing under, a contract under which the 34.1 health maintenance organization has incurred an expense. The 34.2 commissioner has standing to sue, on behalf of a health 34.3 maintenance organization, officers or trustees of the health 34.4 maintenance organization who have breached their fiduciary duty 34.5 in entering into and performing such contracts. 34.6 Sec. 49. Minnesota Statutes 1998, section 62D.20, 34.7 subdivision 1, is amended to read: 34.8 Subdivision 1. [RULEMAKING.] The commissionerof health34.9 may, pursuant to chapter 14, promulgate such reasonable rules as 34.10 are necessary or proper to carry out the provisions of sections 34.11 62D.01 to 62D.30. Included among such rules shall be those 34.12 which provide minimum requirements for the provision of 34.13 comprehensive health maintenance services, as defined in section 34.14 62D.02, subdivision 7, and reasonable exclusions therefrom. 34.15 Nothing in such rules shall force or require a health 34.16 maintenance organization to provide elective, induced abortions, 34.17 except as medically necessary to prevent the death of the 34.18 mother, whether performed in a hospital, other abortion 34.19 facility, or the office of a physician; the rules shall provide 34.20 every health maintenance organization the option of excluding or 34.21 including elective, induced abortions, except as medically 34.22 necessary to prevent the death of the mother, as part of its 34.23 comprehensive health maintenance services. 34.24 Sec. 50. Minnesota Statutes 1998, section 62D.21, is 34.25 amended to read: 34.26 62D.21 [FEES.] 34.27 Every health maintenance organization subject to sections 34.28 62D.01 to 62D.30 shall pay to the commissionerof healthfees as 34.29 prescribed by the commissionerof health pursuant to section34.30144.122for the following: 34.31 (a) Filing an application for a certificate of authority, 34.32 (b) Filing an amendment to a certificate of authority, 34.33 (c) Filing each annual report, and 34.34 (d) Other filings, as specified by rule. 34.35 Sec. 51. Minnesota Statutes 1998, section 62D.211, is 34.36 amended to read: 35.1 62D.211 [RENEWAL FEE.] 35.2 Each health maintenance organization subject to sections 35.3 62D.01 to 62D.30 shall submit to the commissionerof healtheach 35.4 year before June 15 a certificate of authority renewal fee in 35.5 the amount of $10,000 each plus 20 cents per person enrolled in 35.6 the health maintenance organization on December 31 of the 35.7 preceding year. The commissioner may adjust the renewal fee in 35.8 rule under the provisions of chapter 14. 35.9 Sec. 52. Minnesota Statutes 1998, section 62D.22, 35.10 subdivision 4, is amended to read: 35.11 Subd. 4. To the extent that it furthers the purposes of 35.12 sections 62D.01 to 62D.30, the commissionerof healthshall 35.13 attempt to coordinate the operations of sections 62D.01 to 35.14 62D.30 relating to the quality of health care services with the 35.15 operations of United States Code, title 42, sections 1320c to 35.16 1320c-20. The commissioner shall seek and consider 35.17 recommendations from the commissioner of health regarding this 35.18 coordination. 35.19 Sec. 53. Minnesota Statutes 1998, section 62D.22, 35.20 subdivision 10, is amended to read: 35.21 Subd. 10. Any person or committee conducting a review of a 35.22 health maintenance organization or a participating entity, 35.23 pursuant to sections 62D.01 to 62D.30, shall have access to any 35.24 data or information necessary to conduct the review. All data 35.25 or information is subject to admission into evidence in any 35.26 civil action initiated by the commissionerof healthagainst the 35.27 health maintenance organization. The data and information are 35.28 subject to chapter 13. 35.29 Sec. 54. Minnesota Statutes 1998, section 62D.24, is 35.30 amended to read: 35.31 62D.24 [STATE COMMISSIONER OF HEALTH'SAUTHORITY TO 35.32 CONTRACT.] 35.33 The commissionerof health, in carrying out the obligations 35.34 under sections 62D.01 to 62D.30, may contract with the 35.35 commissioner ofcommercehealth or other qualified persons to 35.36 make recommendations concerning the determinations required to 36.1 be made. Such recommendations may be accepted in full or in 36.2 part by the commissionerof health. 36.3 Sec. 55. Minnesota Statutes 1998, section 62D.30, 36.4 subdivision 1, is amended to read: 36.5 Subdivision 1. The commissionerof healthmay establish 36.6 demonstration projects to allow health maintenance organizations 36.7 to extend coverage to: 36.8 (a) Individuals enrolled in Part A or Part B, or both, of 36.9 the Medicare program, Title XVIII of the Social Security Act, 36.10 United States Code, title 42, section 1395 et seq.; 36.11 (b) Groups of fewer than 50 employees where each group is 36.12 covered by a single group health policy; 36.13 (c) Individuals who are not eligible for enrollment in any 36.14 group health maintenance contracts; and 36.15 (d) Low income population groups. 36.16 For purposes of this section, the commissionerof health36.17 may waive compliance with minimum benefits pursuant to sections 36.18 62A.151 and 62D.02, subdivision 7, full financial risk pursuant 36.19 to section 62D.04, subdivision 1, clause (f), open enrollment 36.20 pursuant to section 62D.10, and to applicable rules if there is 36.21 reasonable evidence that the rules prohibit the operation of the 36.22 demonstration project. The commissioner shall provide for 36.23 public comment before any statute or rule is waived. 36.24 Sec. 56. Minnesota Statutes 1998, section 62D.30, 36.25 subdivision 3, is amended to read: 36.26 Subd. 3. A health maintenance organization electing to 36.27 participate in a demonstration project shall apply to the 36.28 commissioner for approval on a form developed by the 36.29 commissioner. The application shall include at least the 36.30 following: 36.31 (a) A statement identifying the population that the project 36.32 is designed to serve; 36.33 (b) A description of the proposed project including a 36.34 statement projecting a schedule of costs and benefits for the 36.35 enrollee; 36.36 (c) Reference to the sections of Minnesota Statutes and 37.1 department ofhealthcommerce rules for which waiver is 37.2 requested; 37.3 (d) Evidence that application of the requirements of 37.4 applicable Minnesota Statutes and department ofhealthcommerce 37.5 rules would, unless waived, prohibit the operation of the 37.6 demonstration project; 37.7 (e) Evidence that another arrangement is available for 37.8 assumption of full financial risk if full financial risk is 37.9 waived under subdivision 1; 37.10 (f) An estimate of the number of years needed to adequately 37.11 demonstrate the project's effects; and 37.12 (g) Other information the commissioner may reasonably 37.13 require. 37.14 Sec. 57. [REPORT; REGULATION OF RISK-BEARING ENTITIES.] 37.15 The commissioners of commerce and health shall study the 37.16 issues involved in consistent regulation of all entities that 37.17 assume financial risks related to health coverage in this 37.18 state. The study must consider all such entities, regardless of 37.19 current licensure or regulation. The commissioners must 37.20 consider laws recently enacted by the state of Ohio on this 37.21 subject and any relevant model laws or regulations adopted or 37.22 under consideration by the National Association of Insurance 37.23 Commissioners. The commissioners shall provide a written 37.24 report, with recommendations, to the legislature in compliance 37.25 with Minnesota Statutes, section 3.195, no later than January 37.26 15, 2000. 37.27 Sec. 58. [EFFECT OF TRANSFER OF RESPONSIBILITIES.] 37.28 Minnesota Statutes, section 15.039, applies to this act. 37.29 Sec. 59. [REPEALER.] 37.30 Minnesota Statutes 1998, section 62D.18, is repealed. 37.31 Sec. 60. [EFFECTIVE DATE.] 37.32 This article is effective July 1, 2000. 37.33 ARTICLE 2 37.34 COMMUNITY INTEGRATED SERVICE NETWORKS, HEALTH 37.35 CARE COOPERATIVES, AND COMMUNITY PURCHASING ARRANGEMENTS 37.36 Section 1. Minnesota Statutes 1998, section 62N.02, 38.1 subdivision 4, is amended to read: 38.2 Subd. 4. [COMMISSIONER.] "Commissioner" means the 38.3 commissioner ofhealthcommerce or the commissioner's designated 38.4 representative. With respect to this chapter, the commissioner 38.5 of health has the same role as under chapter 62D. 38.6 Sec. 2. Minnesota Statutes 1998, section 62N.26, is 38.7 amended to read: 38.8 62N.26 [SHARED SERVICES COOPERATIVE.] 38.9 The commissionerof healthshall establish, or assist in 38.10 establishing, a shared services cooperative organized under 38.11 chapter 308A to make available administrative and legal 38.12 services, technical assistance, provider contracting and billing 38.13 services, and other services to those community integrated 38.14 service networks that choose to participate in the cooperative. 38.15 The commissioner shall provide, to the extent funds are 38.16 appropriated, start-up loans sufficient to maintain the shared 38.17 services cooperative until its operations can be maintained by 38.18 fees and contributions. The cooperative must not be staffed, 38.19 administered, or supervised by the commissionerof health. The 38.20 cooperative shall make use of existing resources that are 38.21 already available in the community, to the extent possible. 38.22 Sec. 3. Minnesota Statutes 1998, section 62N.31, 38.23 subdivision 1, is amended to read: 38.24 Subdivision 1. [GENERAL.] Each health care providing 38.25 entity seeking initial accreditation as an accredited capitated 38.26 provider shall submit to the commissionerof healthsufficient 38.27 information to establish that the applicant has operational 38.28 capacity, facilities, personnel, and financial capability to 38.29 provide the contracted covered services to the enrollees of the 38.30 network for which it seeks accreditation (1) on an ongoing 38.31 basis; and (2) for a period of 120 days following the insolvency 38.32 of the network without receiving payment from the network. 38.33 Accreditation shall continue until abandoned by the accredited 38.34 capitated provider or revoked by the commissioner in accordance 38.35 with subdivision 4. The applicant may establish financial 38.36 capability by demonstrating that the provider amount at risk can 39.1 be covered by or through any of allocated or restricted funds, a 39.2 letter of credit, the taxing authority of the applicant or 39.3 governmental sponsor of the applicant, an unrestricted fund 39.4 balance at least two times the provider amount at risk, 39.5 reinsurance, either purchased directly by the applicant or by 39.6 the community network to which it will be accredited, or any 39.7 other method accepted by the commissioner. Accreditation of a 39.8 health care providing entity shall not in itself limit the right 39.9 of the accredited capitated provider to seek payment of unpaid 39.10 capitated amounts from a community network, whether the 39.11 community network is solvent or insolvent; provided that, if the 39.12 community network is subject to any liquidation, rehabilitation, 39.13 or conservation proceedings, the accredited capitated provider 39.14 shall have the status accorded creditors under section 60B.44, 39.15 subdivision 10. 39.16 Sec. 4. Minnesota Statutes 1998, section 62R.04, 39.17 subdivision 5, is amended to read: 39.18 Subd. 5. [COMMISSIONER.] Unless otherwise specified, 39.19 "commissioner" means the commissioner ofhealth for a health39.20care network cooperative licensed under chapter 62D or 62N and39.21the commissioner ofcommercefor a health care network39.22cooperative licensed under chapter 62C. With respect to this 39.23 chapter, the commissioner of health has the same role as under 39.24 chapter 62D. 39.25 Sec. 5. Minnesota Statutes 1998, section 62R.25, is 39.26 amended to read: 39.27 62R.25 [NOTIFICATION OF CONTRACT; REPORT TO LEGISLATURE.] 39.28(a)Each health provider cooperative shall notify the 39.29office of rural healthcommissioner in writing upon entering a 39.30 contract described in section 62R.17. 39.31(b) The department of health, office of rural health, shall39.32provide an information report to the MinnesotaCare finance39.33division of the house health and human services committee and39.34the senate health care committee no later than January 15, 1999,39.35on the status of direct contracting between health provider39.36cooperatives and self-insured employer plans or qualified40.1employers in accordance with sections 62R.17 to 62R.26. The40.2report shall consider the effects on public policy and on health40.3provider cooperatives of a possible requirement that health40.4provider cooperatives using direct contracting be obligated to40.5become community integrated service networks.40.6 Sec. 6. Minnesota Statutes 1998, section 62T.01, 40.7 subdivision 4, is amended to read: 40.8 Subd. 4. [COMMISSIONER.] "Commissioner" means the 40.9 commissioner ofhealthcommerce. With respect to this chapter, 40.10 the commissioner of health has the same role as under chapter 40.11 62D. 40.12 Sec. 7. [EFFECTIVE DATE.] 40.13 This article is effective July 1, 2000. 40.14 ARTICLE 3 40.15 CONFORMING CHANGES 40.16 Section 1. Minnesota Statutes 1998, section 60B.02, is 40.17 amended to read: 40.18 60B.02 [PERSONS COVERED.] 40.19 The proceedings authorized by sections 60B.01 to 60B.61 may 40.20 be applied to: 40.21 (1) All insurers who are doing, or have done, an insurance 40.22 business in this state, and against whom claims arising from 40.23 that business may exist now or in the future; 40.24 (2) All insurers who purport to do an insurance business in 40.25 this state; 40.26 (3) All insurers who have insureds resident in this state; 40.27 (4) All other persons organized or in the process of 40.28 organizing with the intent to do an insurance business in this 40.29 state; and 40.30 (5) All nonprofit service plan corporations incorporated or 40.31 operating under the Nonprofit Health Service Plan Corporation 40.32 Act, health maintenance organizations operating under chapter 40.33 62D, any health plan incorporated under chapter 317A, all 40.34 fraternal benefit societies operating under chapter 64B, except 40.35 those associations enumerated in section 64B.38, all township 40.36 mutual or other companies operating under chapter 67A, and all 41.1 reciprocals or interinsurance exchanges operating under chapter 41.2 71A. 41.3 Sec. 2. Minnesota Statutes 1998, section 60B.03, 41.4 subdivision 2, is amended to read: 41.5 Subd. 2. [COMMISSIONER.] "Commissioner" means the 41.6 commissioner of commerce of the state of Minnesota and, in that 41.7 commissioner's absence or disability, a deputy or other person 41.8 duly designated to act in that commissioner's place.In the41.9context of rehabilitation or liquidation of a health maintenance41.10organization, "commissioner" means the commissioner of health of41.11the state of Minnesota and, in that commissioner's absence or41.12disability, a deputy or other person duly designated to act in41.13that commissioner's place.41.14 Sec. 3. Minnesota Statutes 1998, section 60B.03, 41.15 subdivision 4, is amended to read: 41.16 Subd. 4. [INSURER.] "Insurer" means any person who is 41.17 doing, has done, purports to do or is licensed to do an 41.18 insurance business and is or has been subject to the authority 41.19 of, or to liquidation, rehabilitation, reorganization, or 41.20 conservation by,athe commissioner. For purposes of sections 41.21 60B.01 to 60B.61, all other persons included under section 41.22 60B.02 shall be deemed to be insurers. 41.23 Sec. 4. Minnesota Statutes 1998, section 60B.15, is 41.24 amended to read: 41.25 60B.15 [GROUNDS FOR REHABILITATION.] 41.26 The commissioner may apply by verified petition to the 41.27 district court for Ramsey county or for the county in which the 41.28 principal office of the insurer is located for an order 41.29 directing the commissioner to rehabilitate a domestic insurer or 41.30 an alien insurer domiciled in this state on any one or more of 41.31 the following grounds: 41.32 (1) Any ground on which the commissioner may apply for an 41.33 order of liquidation under section 60B.20, whenever the 41.34 commissioner believes that the insurer may be successfully 41.35 rehabilitated without substantial increase in the risk of loss 41.36 to creditors of the insurer, its policyholders or to the public; 42.1 (2) That the commissioner has reasonable cause to believe 42.2 that there has been theft from the insurer, wrongful 42.3 sequestration or diversion of the insurer's assets, forgery or 42.4 fraud affecting the insurer or other illegal conduct in, by or 42.5 with respect to the insurer, which endanger assets in an amount 42.6 threatening insolvency of the insurer; 42.7 (3) That substantial and unexplained discrepancies exist 42.8 between the insurer's records and the most recent annual report 42.9 or other official company reports; 42.10 (4) That the insurer, after written demand by the 42.11 commissioner, has failed to remove any person who in fact has 42.12 executive authority in the insurer, whether an officer, manager, 42.13 general agent, employee, or other person, if the person has been 42.14 found by the commissioner after notice and hearing to be 42.15 dishonest or untrustworthy in a way affecting the insurer's 42.16 business such as is the basis for action under section 60A.052; 42.17 (5) That control of the insurer, whether by stock ownership 42.18 or otherwise, and whether direct or indirect, is in one or more 42.19 persons found by the commissioner after notice and hearing to be 42.20 dishonest or untrustworthy such as is the basis for action under 42.21 section 60A.052; 42.22 (6) That the insurer, after written demand by the 42.23 commissioner, has failed within a reasonable period of time to 42.24 terminate the employment and status and all influences on 42.25 management of any person who in fact has executive authority in 42.26 the insurer, whether an officer, manager, general agent, 42.27 employee or other person if the person has refused to submit to 42.28 lawful examination under oath by the commissioner concerning the 42.29 affairs of the insurer, whether in this state or elsewhere; 42.30 (7) That after lawful written demand by the commissioner 42.31 the insurer has failed to submit promptly any of its own 42.32 property, books, accounts, documents, or other records, or those 42.33 of any subsidiary or related company within the control of the 42.34 insurer, or those of any person having executive authority in 42.35 the insurer so far as they pertain to the insurer, to reasonable 42.36 inspection or examination by the commissioner or an authorized 43.1 representative. If the insurer is unable to submit the 43.2 property, books, accounts, documents, or other records of a 43.3 person having executive authority in the insurer, it shall be 43.4 excused from doing so if it promptly and effectively terminates 43.5 the relationship of the person to the insurer; 43.6 (8) That without first obtaining the written consent of the 43.7 commissioner, or if required by law, the written consent of the 43.8 attorney general, the insurer has transferred, or attempted to 43.9 transfer, substantially its entire property or business, or has 43.10 entered into any transaction the effect of which is to merge, 43.11 consolidate, or reinsure substantially its entire property or 43.12 business of any other person; 43.13 (9) That the insurer or its property has been or is the 43.14 subject of an application for the appointment of a receiver, 43.15 trustee, custodian, conservator or sequestrator or similar 43.16 fiduciary of the insurer or its property otherwise than as 43.17 authorized under sections 60B.01 to 60B.61, and that such 43.18 appointment has been made or is imminent, and that such 43.19 appointment might divest the courts of this state of 43.20 jurisdiction or prejudice orderly delinquency proceedings under 43.21 sections 60B.01 to 60B.61; 43.22 (10) That within the previous year the insurer has 43.23 willfully violated its charter or articles of incorporation or 43.24 its bylaws or any applicable insurance law or regulation of any 43.25 state, or of the federal government, or any valid order of the 43.26 commissioner under section 60B.11 in any manner or as to any 43.27 matter which threatens substantial injury to the insurer, its 43.28 creditors, it policyholders or the public, or having become 43.29 aware within the previous year of an unintentional or willful 43.30 violation has failed to take all reasonable steps to remedy the 43.31 situation resulting from the violation and to prevent the same 43.32 violations in the future; 43.33 (11) That the directors of the insurer are deadlocked in 43.34 the management of the insurer's affairs and that the members or 43.35 shareholders are unable to break the deadlock and that 43.36 irreparable injury to the insurer, its creditors, its 44.1 policyholders, or the public is threatened by reason thereof; 44.2 (12) That the insurer has failed to pay for 60 days after 44.3 due date any obligation to this state or any political 44.4 subdivision thereof or any judgment entered in this state, 44.5 except that such nonpayment shall not be a ground until 60 days 44.6 after any good faith effort by the insurer to contest the 44.7 obligation or judgment has been terminated, whether it is before 44.8 the commissioner or in the courts; 44.9 (13) That the insurer has failed to file its annual report 44.10 or other report within the time allowed by law, and after 44.11 written demand by the commissioner has failed to give an 44.12 adequate explanation immediately; 44.13 (14) That two-thirds of the board of directors, or the 44.14 holders of a majority of the shares entitled to vote, or a 44.15 majority of members or policyholders of an insurer subject to 44.16 control by its members or policyholders, consent to 44.17 rehabilitation under sections 60B.01 to 60B.61; 44.18 (15) That the insurer is engaging in a systematic practice 44.19 of reaching settlements with and obtaining releases from 44.20 policyholders or third party claimants and then unreasonably 44.21 delaying payment of or failing to pay the agreed upon 44.22 settlements; 44.23 (16) That the insurer is in such condition that the further 44.24 transaction of business would be hazardous, financially or 44.25 otherwise, to its policyholders, its creditors, or the public; 44.26 (17) That within the previous 12 months the insurer has 44.27 systematically attempted to compromise with its creditors on the 44.28 ground that it is financially unable to pay its claims in full; 44.29 (18)In the context of a health maintenance organization,44.30"insurer" when used in clauses (1) to (17) means "health44.31maintenance organization."In addition to the grounds in clauses 44.32 (1) to (17), any one of the following constitutes grounds for 44.33 rehabilitation of a health maintenance organization: 44.34 (a) the health maintenance organization is unable or is 44.35 expected to be unable to meet its debts as they become due; 44.36 (b) grounds exist under section 62D.042, subdivision 7; 45.1 (c) the health maintenance organization's liabilities 45.2 exceed the current value of its assets, exclusive of intangibles 45.3 and, where the guaranteeing organization's financial condition 45.4 no longer meets the requirements of sections 62D.041 and 45.5 62D.042, exclusive of any deposits, letters of credit, or 45.6 guarantees provided by any guaranteeing organization under 45.7 chapter 62D; 45.8 (d) in addition to grounds under clause (16), within the 45.9 last year the health maintenance organization has failed, and 45.10 the commissionerof healthexpects such failure to continue in 45.11 the future, to make comprehensive medical care adequately 45.12 available and accessible to its enrollees and the health 45.13 maintenance organization has not successfully implemented a plan 45.14 of corrective action pursuant to section 62D.121, subdivision 7; 45.15 and 45.16 (e) in addition to grounds under clause (16), within the 45.17 last year the directors or officers of the health maintenance 45.18 organization willfully violated the requirements of section 45.19 317A.251, or having become aware within the previous year of an 45.20 unintentional or willful violation of section 317A.251, have 45.21 failed to take all reasonable steps to remedy the situation 45.22 resulting from the violation and to prevent the same violation 45.23 in the future; 45.24 (19) An affiliate of the insurer has been placed in 45.25 conservatorship, rehabilitation, liquidation, or other court 45.26 supervision such that the insurer's financial condition may be 45.27 jeopardized. 45.28 Sec. 5. Minnesota Statutes 1998, section 60B.20, is 45.29 amended to read: 45.30 60B.20 [GROUNDS FOR LIQUIDATION.] 45.31 The commissioner may apply by verified petition to the 45.32 district court for Ramsey county or for the county in which the 45.33 principal office of the insurer is located for an order to 45.34 liquidate a domestic insurer or an alien insurer domiciled in 45.35 this state on any one or more of the following grounds: 45.36 (1) Any ground on which the commissioner may apply for an 46.1 order of rehabilitation under section 60B.15, whenever the 46.2 commissioner believes that attempts to rehabilitate the insurer 46.3 would substantially increase the risk of loss to its creditors, 46.4 its policyholders, or the public, or would be futile, or that 46.5 rehabilitation would serve no useful purpose; 46.6 (2) That the insurer is or is about to become insolvent; 46.7 (3) That the insurer has not transacted the business for 46.8 which it was organized or incorporated during the previous 12 46.9 months or has transacted only a token such business during that 46.10 period, although authorized to do so throughout that period, or 46.11 that more than 12 months after incorporation it has failed to 46.12 become authorized to do the business for which it was organized 46.13 or incorporated; 46.14 (4) That the insurer has commenced, or within the previous 46.15 year has attempted to commence, voluntary dissolution or 46.16 liquidation otherwise than as provided in section 60B.04, 46.17 subdivision 3 in the case of a solvent insurer; 46.18 (5) That the insurer has concealed records or assets from 46.19 the commissioner or improperly removed them from the 46.20 jurisdiction, or the commissioner believes that the insurer is 46.21 about to do so; 46.22 (6) That the insurer does not satisfy the requirements that 46.23 would be applicable if it were seeking initial authorization in 46.24 this state to do the business for which it was organized or 46.25 incorporated, except for: 46.26 (i) Requirements that are intended to apply only at the 46.27 time the initial authorization to do business is obtained, and 46.28 not thereafter; and 46.29 (ii) Requirements that are expressly made inapplicable by 46.30 the laws establishing the requirements; 46.31 (7) That the holders of two-thirds of the shares entitled 46.32 to vote, or two-thirds of the members or policyholders entitled 46.33 to vote in an insurer controlled by its members or 46.34 policyholders, have consented to a petition; 46.35 (8)In the context of a health maintenance organization,46.36"insurer" when used in clauses (1) to (7) means "health47.1maintenance organization."In addition to the grounds in clauses 47.2 (1) to (7), any one of the following constitutes grounds for 47.3 liquidation of a health maintenance organization: 47.4 (i) the health maintenance organization is unable or is 47.5 expected to be unable to meet its debts as they become due; 47.6 (ii) grounds exist under section 62D.042, subdivision 7; 47.7 (iii) the health maintenance organization's liabilities 47.8 exceed the current value of its assets, exclusive of intangibles 47.9 and, where the guaranteeing organization's financial condition 47.10 no longer meets the requirements of sections 62D.041 and 47.11 62D.042, exclusive of any deposits, letters of credit, or 47.12 guarantees provided by any guaranteeing organization under 47.13 chapter 62D; 47.14 (iv) within the last year the health maintenance 47.15 organization has failed, and the commissionerof healthexpects 47.16 failure to continue in the future, to make comprehensive medical 47.17 care adequately available and accessible to its enrollees and 47.18 the health maintenance organization has not successfully 47.19 implemented a plan of corrective action pursuant to section 47.20 62D.121, subdivision 7; and 47.21 (v) within the last year the directors or officers of the 47.22 health maintenance organization willfully violated the 47.23 requirements of section 317A.251, or having become aware within 47.24 the previous year of an unintentional or willful violation of 47.25 section 317A.251, have failed to take all reasonable steps to 47.26 remedy the situation resulting from the violation and to prevent 47.27 the same violation in the future. 47.28 Sec. 6. Minnesota Statutes 1998, section 60G.01, 47.29 subdivision 2, is amended to read: 47.30 Subd. 2. [COMMISSIONER.] "Commissioner" means the 47.31 commissioner of commerce, except that "commissioner" means the47.32commissioner of health for administrative supervision of health47.33maintenance organizations. 47.34 Sec. 7. Minnesota Statutes 1998, section 60G.01, 47.35 subdivision 4, is amended to read: 47.36 Subd. 4. [DEPARTMENT.] "Department" means the department 48.1 of commerce, except that "department" means the department of48.2health for administrative supervision of health maintenance48.3organizations. 48.4 Sec. 8. Minnesota Statutes 1998, section 62A.61, is 48.5 amended to read: 48.6 62A.61 [DISCLOSURE OF METHODS USED BY HEALTH CARRIERS TO 48.7 DETERMINE USUAL AND CUSTOMARY FEES.] 48.8 (a) A health carrier that bases reimbursement to health 48.9 care providers upon a usual and customary fee must maintain in 48.10 its office a copy of a description of the methodology used to 48.11 calculate fees including at least the following: 48.12 (1) the frequency of the determination of usual and 48.13 customary fees; 48.14 (2) a general description of the methodology used to 48.15 determine usual and customary fees; and 48.16 (3) the percentile of usual and customary fees that 48.17 determines the maximum allowable reimbursement. 48.18 (b) A health carrier must provide a copy of the information 48.19 described in paragraph (a) to the commissionerof health or the48.20commissioner of commerce,upon request. 48.21 (c) The commissionerof health or the commissioner of48.22commerce, as appropriate,may use to enforce this section any 48.23 enforcement powers otherwise available to the commissioner with 48.24 respect to the health carrier. The commissionerof health or48.25commerce, as appropriate,may require health carriers to provide 48.26 the information required under this section and may use any 48.27 powers granted under other laws relating to the regulation of 48.28 health carriers to enforce compliance. 48.29 (d) For purposes of this section, "health carrier" has the 48.30 meaning given in section 62A.011. 48.31 Sec. 9. Minnesota Statutes 1998, section 62L.02, 48.32 subdivision 8, is amended to read: 48.33 Subd. 8. [COMMISSIONER.] "Commissioner" means the 48.34 commissioner of commercefor health carriers subject to the48.35jurisdiction of the department of commerce or the commissioner48.36of health for health carriers subject to the jurisdiction of the49.1department of health,or therelevantcommissioner's designated 49.2 representative.For purposes of sections 62L.13 to 62L.22,49.3"commissioner" means the commissioner of commerce or that49.4commissioner's designated representative.49.5 Sec. 10. Minnesota Statutes 1998, section 62L.05, 49.6 subdivision 12, is amended to read: 49.7 Subd. 12. [DEMONSTRATION PROJECTS.] Nothing in this 49.8 chapter prohibits a health maintenance organization from 49.9 offering a demonstration project authorized under section 62D.30. 49.10 The commissionerof healthmay approve a demonstration project 49.11 which offers benefits that do not meet the requirements of a 49.12 small employer plan if the commissioner finds that the 49.13 requirements of section 62D.30 are otherwise met. 49.14 Sec. 11. Minnesota Statutes 1998, section 62L.08, 49.15 subdivision 10, is amended to read: 49.16 Subd. 10. [RATING REPORT.] Beginning January 1, 1995, and 49.17 annually thereafter, thecommissioners of health and49.18commercecommissioner shall provide ajointreport to the 49.19 legislature on the effect of the rating restrictions required by 49.20 this section and the appropriateness of proceeding with 49.21 additional rate reform. Each report must include an analysis of 49.22 the availability of health care coverage due to the rating 49.23 reform, the equitable and appropriate distribution of risk and 49.24 associated costs, the effect on the self-insurance market, and 49.25 any resulting or anticipated change in health plan design and 49.26 market share and availability of health carriers. 49.27 Sec. 12. Minnesota Statutes 1998, section 62L.08, 49.28 subdivision 11, is amended to read: 49.29 Subd. 11. [LOSS RATIO STANDARDS.] Notwithstanding section 49.30 62A.02, subdivision 3, relating to loss ratios, each policy or 49.31 contract form used with respect to a health benefit plan 49.32 offered, or issued in the small employer market, is subject, 49.33 beginning July 1, 1993, to section 62A.021.The commissioner of49.34health has, with respect to carriers under that commissioner's49.35jurisdiction, all of the powers of the commissioner of commerce49.36under that section.50.1 Sec. 13. Minnesota Statutes 1998, section 62M.11, is 50.2 amended to read: 50.3 62M.11 [COMPLAINTS TO COMMERCEOR HEALTH.] 50.4 Notwithstanding the provisions of sections 62M.01 to 50.5 62M.16, an enrollee may file a complaint regarding a 50.6 determination not to certify directly to the commissioner 50.7responsible for regulating the utilization review50.8organizationof commerce. 50.9 Sec. 14. Minnesota Statutes 1998, section 62M.16, is 50.10 amended to read: 50.11 62M.16 [RULEMAKING.] 50.12 If it is determined that rules are reasonable and necessary 50.13 to accomplish the purpose of sections 62M.01 to 62M.16, the 50.14 rules must be adoptedthrough a joint rulemaking process by both50.15the department of commerce and the department of healthby the 50.16 commissioner of commerce. 50.17 Sec. 15. Minnesota Statutes 1998, section 62Q.01, 50.18 subdivision 2, is amended to read: 50.19 Subd. 2. [COMMISSIONER.] "Commissioner" means the 50.20 commissioner ofhealth for purposes of regulating health50.21maintenance organizations, and community integrated service50.22networks, or the commissioner ofcommercefor purposes of50.23regulating all other health plan companies. For all other50.24purposes, "commissioner" means the commissioner of health. 50.25 Sec. 16. Minnesota Statutes 1998, section 62Q.07, is 50.26 amended to read: 50.27 62Q.07 [ACTION PLANS.] 50.28 Subdivision 1. [ACTION PLANS REQUIRED.] (a) To increase 50.29 public awareness and accountability of health plan companies, 50.30 all health plan companies that issue or renew a health plan, as 50.31 defined in section 62Q.01, must annually file with the 50.32applicablecommissioner an action plan that satisfies the 50.33 requirements of this section beginning July 1, 1994, as a 50.34 condition of doing business in Minnesota. For purposes of this 50.35 subdivision, "health plan" includes the coverages described in 50.36 section 62A.011, subdivision 3, clause (10). Each health plan 51.1 company must also file its action plan with the information 51.2 clearinghouse. Action plans are required solely to provide 51.3 information to consumers, purchasers, and the larger community 51.4 as a first step toward greater accountability of health plan 51.5 companies. The sole function of the commissioner in relation to 51.6 the action plans is to ensure that each health plan company 51.7 files a complete action plan, that the action plan is truthful 51.8 and not misleading, and that the action plan is reviewed by 51.9 appropriate community agencies. 51.10 (b) Ifathe commissionerresponsible for regulating a51.11health plan company required to file an action plan under this51.12sectionhas reason to believe an action plan is false or 51.13 misleading, the commissioner may conduct an investigation to 51.14 determine whether the action plan is truthful and not 51.15 misleading, and may require the health plan company to submit 51.16 any information that the commissioner reasonably deems necessary 51.17 to complete the investigation. If the commissioner determines 51.18 that an action plan is false or misleading, the commissioner may 51.19 require the health plan company to file an amended plan or may 51.20 take any action authorized under chapter 72A. 51.21 Subd. 2. [CONTENTS OF ACTION PLANS.] (a) An action plan 51.22 must include a detailed description of all of the health plan 51.23 company's methods and procedures, standards, qualifications, 51.24 criteria, and credentialing requirements for designating the 51.25 providers who are eligible to participate in the health plan 51.26 company's provider network, including any limitations on the 51.27 numbers of providers to be included in the network. This 51.28 description must be updated by the health plan company and filed 51.29 with theapplicable agencycommissioner on a quarterly basis. 51.30 (b) An action plan must include the number of full-time 51.31 equivalent physicians, by specialty, nonphysician providers, and 51.32 allied health providers used to provide services. The action 51.33 plan must also describe how the health plan company intends to 51.34 encourage the use of nonphysician providers, midlevel 51.35 practitioners, and allied health professionals, through at least 51.36 consumer education, physician education, and referral and 52.1 advisement systems. The annual action plan must also include 52.2 data that is broken down by type of provider, reflecting actual 52.3 utilization of midlevel practitioners and allied professionals 52.4 by enrollees of the health plan company during the previous 52.5 year.Until July 1, 1995, a health plan company may use52.6estimates if actual data is not available.For purposes of this 52.7 paragraph, "provider" has the meaning given in section 62J.03, 52.8 subdivision 8. 52.9 (c) An action plan must include a description of the health 52.10 plan company's policy on determining the number and the type of 52.11 providers that are necessary to deliver cost-effective health 52.12 care to its enrollees. The action plan must also include the 52.13 health plan company's strategy, including provider recruitment 52.14 and retention activities, for ensuring that sufficient providers 52.15 are available to its enrollees. 52.16 (d) An action plan must include a description of actions 52.17 taken or planned by the health plan company to ensure that 52.18 information from report cards, outcome studies, and complaints 52.19 is used internally to improve quality of the services provided 52.20 by the health plan company. 52.21 (e) An action plan must include a detailed description of 52.22 the health plan company's policies and procedures for enrolling 52.23 and serving high risk and special needs populations. This 52.24 description must also include the barriers that are present for 52.25 the high risk and special needs population and how the health 52.26 plan company is addressing these barriers in order to provide 52.27 greater access to these populations. "High risk and special 52.28 needs populations" includes, but is not limited to, recipients 52.29 of medical assistance, general assistance medical care, and 52.30 MinnesotaCare; persons with chronic conditions or disabilities; 52.31 individuals within certain racial, cultural, and ethnic 52.32 communities; individuals and families with low income; 52.33 adolescents; the elderly; individuals with limited or no English 52.34 language proficiency; persons with high-cost preexisting 52.35 conditions; homeless persons; chemically dependent persons; 52.36 persons with serious and persistent mental illness; children 53.1 with severe emotional disturbance; and persons who are at high 53.2 risk of requiring treatment. For purposes of this paragraph, 53.3 "provider" has the meaning given in section 62J.03, subdivision 53.4 8. 53.5 (f) An action plan must include a general description of 53.6 any action the health plan company has taken and those it 53.7 intends to take to offer health coverage options to rural 53.8 communities and other communities not currently served by the 53.9 health plan company. 53.10 (g) A health plan company other than a large managed care 53.11 plan company may satisfy any of the requirements of the action 53.12 plan in paragraphs (a) to (f) by stating that it has no 53.13 policies, procedures, practices, or requirements, either written 53.14 or unwritten, or formal or informal, and has undertaken no 53.15 activities or plans on the issues required to be addressed in 53.16 the action plan, provided that the statement is truthful and not 53.17 misleading. For purposes of this paragraph, "large managed care 53.18 plan company" means a health maintenance organization or other 53.19 health plan company that employs or contracts with health care 53.20 providers, that has more than 50,000 enrollees in this state. 53.21 If a health plan company employs or contracts with providers for 53.22 some of its health plans and does not do so for other health 53.23 plans that it offers, the health plan company is a large managed 53.24 care plan company if it has more than 50,000 enrollees in this 53.25 state in health plans for which it does employ or contract with 53.26 providers. 53.27 Sec. 17. Minnesota Statutes 1998, section 62Q.075, 53.28 subdivision 4, is amended to read: 53.29 Subd. 4. [REVIEW.] Upon receipt of the plan, the 53.30appropriatecommissioner shall provide a copy to the regional 53.31 coordinating boards, local community health boards, and other 53.32 relevant community organizations within the managed care 53.33 organization's service area. After reviewing the plan, these 53.34 community groups may submit written comments on the plan to 53.35eitherthe commissioner ofhealth orcommerce, as applicable,53.36 and may advise the commissioner of the managed care 54.1 organization's effectiveness in assisting to achieve regional 54.2 public health goals. The plan may be reviewed by the county 54.3 boards, or city councils acting as a local board of health in 54.4 accordance with chapter 145A, within the managed care 54.5 organization's service area to determine whether the plan is 54.6 consistent with the goals and objectives of the plans required 54.7 under chapters 145A and 256E and whether the plan meets the 54.8 needs of the community. The county board, or applicable city 54.9 council, may also review and make recommendations on the 54.10 availability and accessibility of services provided by the 54.11 managed care organization. The county board, or applicable city 54.12 council, may submit written comments to theappropriate54.13 commissioner, and may advise the commissioner of the managed 54.14 care organization's effectiveness in assisting to meet the needs 54.15 and goals as defined under the responsibilities of chapters 145A 54.16 and 256E.The commissioner of health shall develop54.17recommendations to utilize the written comments submitted as54.18part of the licensure process to ensure local public54.19accountability. These recommendations shall be reported to the54.20legislative commission on health care access by January 15,54.211996.Copies of these written comments must be provided to the 54.22 managed care organization. The plan and any comments submitted 54.23 must be filed with the information clearinghouse to be 54.24 distributed to the public. 54.25 Sec. 18. Minnesota Statutes 1998, section 62Q.105, 54.26 subdivision 6, is amended to read: 54.27 Subd. 6. [RECORDKEEPING.] Health plan companies shall 54.28 maintain records of all enrollee complaints and their 54.29 resolutions. These records must be retained for five years, and 54.30 must be made available to theappropriatecommissioner upon 54.31 request. 54.32 Sec. 19. Minnesota Statutes 1998, section 62Q.105, 54.33 subdivision 7, is amended to read: 54.34 Subd. 7. [REPORTING.] Each health plan company shall 54.35 submit to theappropriatecommissioner, as part of the company's 54.36 annual filing, data on the number and type of complaints that 55.1 are not resolved within 30 days. A health plan company shall 55.2 also make this information available to the public upon request. 55.3 Sec. 20. Minnesota Statutes 1998, section 62Q.11, is 55.4 amended to read: 55.5 62Q.11 [DISPUTE RESOLUTION.] 55.6 Subdivision 1. [ESTABLISHED.] Thecommissioners of health55.7and commercecommissioner shall make dispute resolution 55.8 processes available to encourage early settlement of disputes in 55.9 order to avoid the time and cost associated with litigation and 55.10 other formal adversarial hearings. For purposes of this 55.11 section, "dispute resolution" means the use of negotiation, 55.12 mediation, arbitration, mediation-arbitration, neutral fact 55.13 finding, and minitrials. These processes shall be nonbinding 55.14 unless otherwise agreed to by all parties to the dispute. 55.15 Subd. 2. [REQUIREMENTS.] (a) If an enrollee, health care 55.16 provider, or applicant for network provider status chooses to 55.17 use a dispute resolution process prior to the filing of a formal 55.18 claim or of a lawsuit, the health plan company must participate. 55.19 (b) If an enrollee, health care provider, or applicant for 55.20 network provider status chooses to use a dispute resolution 55.21 process after the filing of a lawsuit, the health plan company 55.22 must participate in dispute resolution, including, but not 55.23 limited to, alternative dispute resolution under rule 114 of the 55.24 Minnesota general rules of practice. 55.25 (c) Thecommissioners of health and commercecommissioner 55.26 shall inform and educate health plan companies' enrollees about 55.27 dispute resolution and its benefits, and shall establish 55.28 appropriate cost-sharing requirements for parties taking part in 55.29 alternative dispute resolution. 55.30 (d) A health plan company may encourage but not require an 55.31 enrollee to submit a complaint to alternative dispute resolution. 55.32 Sec. 21. Minnesota Statutes 1998, section 62Q.22, 55.33 subdivision 2, is amended to read: 55.34 Subd. 2. [REGISTRATION.] A community health clinic that 55.35 offers a prepaid option under this section must register on an 55.36 annual basis with the commissionerof health. 56.1 Sec. 22. Minnesota Statutes 1998, section 62Q.22, 56.2 subdivision 6, is amended to read: 56.3 Subd. 6. [INFORMATION TO BE PROVIDED.] (a) A community 56.4 health clinic must provide an individual or family who purchases 56.5 a prepaid option a clear and concise written statement that 56.6 includes the following information: 56.7 (1) the health care services that the prepaid option 56.8 covers; 56.9 (2) any exclusions or limitations on the health care 56.10 services offered, including any preexisting condition 56.11 limitations, cost-sharing arrangements, or prior authorization 56.12 requirements; 56.13 (3) where the health care services may be obtained; 56.14 (4) a description of the clinic's method for resolving 56.15 patient complaints, including a description of how a patient can 56.16 file a complaint with the department ofhealthcommerce; and 56.17 (5) a description of the conditions under which the prepaid 56.18 option may be canceled or terminated. 56.19 (b) The commissionerof healthmust approve a copy of the 56.20 written statement before the community health clinic may offer 56.21 the prepaid option described in this section. 56.22 Sec. 23. Minnesota Statutes 1998, section 62Q.22, 56.23 subdivision 7, is amended to read: 56.24 Subd. 7. [COMPLAINT PROCESS.] (a) A community health 56.25 clinic that offers a prepaid option under this section must 56.26 establish a complaint resolution process. As an alternative to 56.27 establishing its own process, a community health clinic may use 56.28 the complaint process of another organization. 56.29 (b) A community health clinic must make reasonable efforts 56.30 to resolve complaints and to inform complainants in writing of 56.31 the clinic's decision within 60 days of receiving the complaint. 56.32 (c) A community health clinic that offers a prepaid option 56.33 under this section must report all complaints that are not 56.34 resolved within 60 days to the commissionerof health. 56.35 Sec. 24. Minnesota Statutes 1998, section 62Q.32, is 56.36 amended to read: 57.1 62Q.32 [LOCAL OMBUDSPERSON.] 57.2 County board or community health service agencies may 57.3 establish an office of ombudsperson to provide a system of 57.4 consumer advocacy for persons receiving health care services 57.5 through a health plan company. The ombudsperson's functions may 57.6 include, but are not limited to: 57.7 (a) mediation or advocacy on behalf of a person accessing 57.8 the complaint and appeal procedures to ensure that necessary 57.9 medical services are provided by the health plan company; and 57.10 (b) investigation of the quality of services provided to a 57.11 person and determine the extent to which quality assurance 57.12 mechanisms are needed or any other system change may be needed. 57.13The commissioner of health shall make recommendations for57.14funding these functions including the amount of funding needed57.15and a plan for distribution. The commissioner shall submit57.16these recommendations to the legislative commission on health57.17care access by January 15, 1996.57.18 Sec. 25. Minnesota Statutes 1998, section 62Q.51, 57.19 subdivision 3, is amended to read: 57.20 Subd. 3. [RATE APPROVAL.] The premium rates and cost 57.21 sharing requirements for each option must be submitted to the 57.22 commissionerof health or the commissioner of commerceas 57.23 required by law. A health plan that includes lower enrollee 57.24 cost sharing for services provided by network providers than for 57.25 services provided by out-of-network providers, or lower enrollee 57.26 cost sharing for services provided with prior authorization or 57.27 second opinion than for services provided without prior 57.28 authorization or second opinion, qualifies as a point-of-service 57.29 option. 57.30 Sec. 26. Minnesota Statutes 1998, section 62Q.525, 57.31 subdivision 3, is amended to read: 57.32 Subd. 3. [REQUIRED COVERAGE.] (a) Every type of coverage 57.33 included in subdivision 1 that provides coverage for drugs may 57.34 not exclude coverage of a drug for the treatment of cancer on 57.35 the ground that the drug has not been approved by the federal 57.36 Food and Drug Administration for the treatment of cancer if the 58.1 drug is recognized for treatment of cancer in one of the 58.2 standard reference compendia or in one article in the medical 58.3 literature, as defined in subdivision 2. 58.4 (b) Coverage of a drug required by this subdivision 58.5 includes coverage of medically necessary services directly 58.6 related to and required for appropriate administration of the 58.7 drug. 58.8 (c) Coverage required by this subdivision does not include 58.9 coverage of a drug not listed on the formulary of the coverage 58.10 included in subdivision 1. 58.11 (d) Coverage of a drug required under this subdivision must 58.12 not be subject to any copayment, coinsurance, deductible, or 58.13 other enrollee cost-sharing greater than the coverage included 58.14 in subdivision 1 applies to other drugs. 58.15 (e) The commissionerof commerce or health, as appropriate,58.16 may direct a person that issues coverage included in subdivision 58.17 1 to make payments required by this section. 58.18 Sec. 27. Minnesota Statutes 1998, section 72A.139, 58.19 subdivision 2, is amended to read: 58.20 Subd. 2. [DEFINITIONS.] (a) As used in this section, 58.21 "commissioner" means the commissioner of commercefor health58.22plan companies and other insurers regulated by that commissioner58.23and the commissioner of health for health plan companies58.24regulated by that commissioner. 58.25 (b) As used in this section, a "genetic test" means a 58.26 presymptomatic test of a person's genes, gene products, or 58.27 chromosomes for the purpose of determining the presence or 58.28 absence of a gene or genes that exhibit abnormalities, defects, 58.29 or deficiencies, including carrier status, that are known to be 58.30 the cause of a disease or disorder, or are determined to be 58.31 associated with a statistically increased risk of development of 58.32 a disease or disorder. "Genetic test" does not include a 58.33 cholesterol test or other test not conducted for the purpose of 58.34 determining the presence or absence of a person's gene or genes. 58.35 (c) As used in this section, "health plan" has the meaning 58.36 given in section 62Q.01, subdivision 3. 59.1 (d) As used in this section, "health plan company" has the 59.2 meaning given in section 62Q.01, subdivision 4. 59.3 (e) As used in this section, "individual" means an 59.4 applicant for coverage or a person already covered by the health 59.5 plan company or other insurer. 59.6 Sec. 28. [REPEALER.] 59.7 Minnesota Statutes 1998, sections 62L.11, subdivision 2; 59.8 and 62Q.45, subdivision 1, are repealed. 59.9 Sec. 29. [EFFECTIVE DATE.] 59.10 This article is effective July 1, 2000.