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Minnesota Legislature

Office of the Revisor of Statutes

HF 2725

as introduced - 90th Legislature (2017 - 2018) Posted on 03/21/2018 12:25pm

KEY: stricken = removed, old language.
underscored = added, new language.

Current Version - as introduced

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A bill for an act
relating to human services; requiring the development of a new county-based
eligibility determination system for medical assistance and MinnesotaCare;
requiring the commissioner of revenue to seek a waiver to determine eligibility
for premium tax credits and cost-sharing reductions and assess eligibility for
medical assistance and MinnesotaCare; providing legislative oversight of certain
expenditures from the state systems account; appropriating money; amending
Minnesota Statutes 2016, sections 62K.02, subdivision 1; 256.014, subdivision 2;
256L.02, subdivision 2; proposing coding for new law in Minnesota Statutes,
chapters 256; 270C; repealing Minnesota Statutes 2016, sections 13.7191,
subdivision 14a; 13D.08, subdivision 5a; 62A.011, subdivision 6; 62K.03,
subdivision 9; 62V.01; 62V.02; 62V.03; 62V.04; 62V.05; 62V.051; 62V.055;
62V.06; 62V.07; 62V.08; 62V.09; 62V.10; 62V.11, subdivisions 1, 2, 4, 5; 256L.01,
subdivision 6; Minnesota Rules, parts 7700.0010; 7700.0020; 7700.0030;
7700.0040; 7700.0050; 7700.0060; 7700.0070; 7700.0080; 7700.0090; 7700.0100;
7700.0101; 7700.0105.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

ARTICLE 1

COUNTY-BASED ELIGIBILITY DETERMINATION SYSTEM

Section 1.

Minnesota Statutes 2016, section 256.014, subdivision 2, is amended to read:


Subd. 2.

State systems account created.

new text begin(a) new text endA state systems account is created in the
state treasury. Money collected by the commissioner of human services for the programs
in subdivision 1 must be deposited in the account. Money in the state systems account and
federal matching money is appropriated to the commissioner of human services for purposes
of this sectionnew text begin and section 256.0145new text end.new text begin Any unexpended balance in the appropriations for
information systems projects for MAXIS, PRISM, MMIS, ISDS, METS, SSIS, or the
county-based eligibility determination system does not cancel and is available for ongoing
development and operations, subject to review by the Legislative Advisory Commission
under paragraphs (b) and (c).
new text end

new text begin (b) No unexpended balance under paragraph (a) may be expended by the commissioner
of human services until the commissioner of management and budget has submitted the
proposed expenditure to the members of the Legislative Advisory Commission for review
and recommendation. If the commission makes a positive recommendation or no
recommendation, or if the commission has not reviewed the request within 20 days after
the date the proposed expenditure was submitted, the commissioner of management and
budget may approve the proposed expenditure. If the commission recommends further
review of the proposed expenditure, the commissioner shall provide additional information
to the commission. If the commission makes a negative recommendation on the proposed
expenditure within ten days of receiving further information, the commissioner shall not
approve the proposed expenditure. If the commission makes a positive recommendation or
no recommendation within ten days of receiving further information, the commissioner may
approve the proposed expenditure.
new text end

new text begin (c) A recommendation of the commission must be made at a meeting of the commission
unless a written recommendation is signed by all members entitled to vote on the item as
specified in section 3.30, subdivision 2. A recommendation of the commission must be
made by a majority of the commission.
new text end

Sec. 2.

new text begin [256.0145] COUNTY-BASED ELIGIBILITY DETERMINATION SYSTEM
FOR PUBLIC HEALTH CARE PROGRAMS.
new text end

new text begin Subdivision 1. new text end

new text begin Information technology steering committee. new text end

new text begin (a) An information
technology steering committee shall be established. The steering committee shall consist
of:
new text end

new text begin (1) two county commissioners appointed by a statewide organization representing all
Minnesota counties. One commissioner shall be from a county within the seven-county
metropolitan area, and one commissioner shall be from a county outside the seven-county
metropolitan area;
new text end

new text begin (2) two county human services directors appointed by a statewide organization
representing human services departments in all Minnesota counties. One human services
director shall be from a county within the seven-county metropolitan area, and one human
services director shall be from a county outside the seven-county metropolitan area;
new text end

new text begin (3) two members appointed by the commissioner of human services; and
new text end

new text begin (4) one nonvoting member appointed by the chief information officer of the Office of
MN.IT Services, who shall serve as a chairperson for the steering committee.
new text end

new text begin (b) Initial appointments to the steering committee shall be made by August 15, 2018,
and the chairperson shall convene the first meeting of the steering committee no later than
September 1, 2018. The Department of Human Services shall provide administrative support
to the steering committee.
new text end

new text begin (c) The steering committee is subject to chapter 13D.
new text end

new text begin Subd. 2. new text end

new text begin County-based eligibility determination and enrollment system. new text end

new text begin (a) The
information technology steering committee established under subdivision 1 shall direct the
development, implementation, and ongoing operation of a county-based eligibility
determination system for all medical assistance and MinnesotaCare enrollees. The
county-based system shall replace the Minnesota eligibility system as defined in section
62V.055, subdivision 1, and existing state- or county-based eligibility determination systems
used to determine applicant eligibility for medical assistance and MinnesotaCare. The new
county-based system must:
new text end

new text begin (1) have the capacity to interface with the federal information technology platform
regarding preliminary assessments of eligibility for medical assistance and MinnesotaCare
made on the federal platform; and
new text end

new text begin (2) allow county agencies to use the new county-based system to make final eligibility
determinations for medical assistance and MinnesotaCare and to enroll eligible individuals
in those programs.
new text end

new text begin (b) The steering committee shall develop a timeline and implementation plan to transition
from the Minnesota eligibility system and existing state- and county-based systems to the
new county-based eligibility determination system. The steering committee may contract
with one or more vendors to develop and implement the new county-based system.
new text end

new text begin Subd. 3. new text end

new text begin Costs. new text end

new text begin All costs for the information technology steering committee and for
developing and implementing the new county-based eligibility determination system must
be paid using state and federal funds deposited in the state systems account established
under section 256.014, subdivision 2, and be designated for the modernization of human
services information technology systems.
new text end

Sec. 3.

Minnesota Statutes 2016, section 256L.02, subdivision 2, is amended to read:


Subd. 2.

Commissioner's duties.

(a) deleted text beginThe commissioner shall establish an office for the
state administration of this plan
deleted text endnew text begin The state agency shall supervise the determination of
eligibility for MinnesotaCare applicants and enrollees by county agencies
new text end. The plan shall
be used to provide covered health services for eligible persons. Payment for these services
shall be made to all participating entities under contract with the commissioner. The
commissioner shall adopt rules to administer the MinnesotaCare program. The commissioner
shall establish marketing efforts to encourage potentially eligible persons to receive
information about the program and about other medical care programs administered or
supervised by the Department of Human Services.

(b) A toll-free telephone number and Web site must be used to provide information
about medical programs and to promote access to the covered services.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective upon implementation of the county-based
eligibility determination system established according to Minnesota Statutes, section
256.0145. The commissioner of human services shall notify the revisor of statutes of the
implementation date.
new text end

Sec. 4.

new text begin [270C.031] WAIVER TO ALLOW DETERMINATION OF ELIGIBILITY
BY THE COMMISSIONER.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For purposes of this section, the following terms have
the meanings given.
new text end

new text begin (b) "Affordable Care Act" has the meaning given in section 62A.011, subdivision 1a.
new text end

new text begin (c) "Health plan" has the meaning given in section 62Q.01, subdivision 3.
new text end

new text begin (d) "Health plan company" has the meaning given in section 62Q.01, subdivision 4.
new text end

new text begin (e) "Insurance producer" has the meaning given in section 60K.31, subdivision 6.
new text end

new text begin Subd. 2. new text end

new text begin Waiver application. new text end

new text begin (a) The commissioner, in consultation with the
commissioners of human services and commerce, shall request a waiver from the Centers
for Medicare and Medicaid Services under section 1332 of the Affordable Care Act to
implement subdivisions 3 to 6 beginning January 1, 2020. The commissioner shall submit
the waiver request by October 1, 2018.
new text end

new text begin (b) The waiver must:
new text end

new text begin (1) allow the state to determine eligibility for, and the amount of, advanced premium
tax credits and cost-sharing subsidies through the Department of Revenue, rather than
through a state or federal exchange; and
new text end

new text begin (2) require the commissioner of revenue to assess eligibility for medical assistance and
MinnesotaCare using a county-based eligibility determination system, with final
determinations of eligibility for those programs being made by the commissioner of human
services.
new text end

new text begin (c) The commissioner shall make the waiver application available to the public on the
agency's Web site and shall notify the chairs and ranking minority members of the legislative
committees with jurisdiction over health and human services and insurance of any federal
action related to the waiver request.
new text end

new text begin Subd. 3. new text end

new text begin Determination of eligibility for and amount of tax credits and cost-sharing
reductions.
new text end

new text begin (a) The commissioner shall determine applicant eligibility for advanced premium
tax credits and cost-sharing reductions under the Affordable Care Act. To determine
eligibility, the commissioner may access all necessary federal and state data sources,
including but not limited to the federal information technology platform. The commissioner
shall coordinate all eligibility determinations and evaluations related to advanced premium
tax credits and cost-sharing reductions with the federal Internal Revenue Service and the
United States Secretary of Health and Human Services.
new text end

new text begin (b) Upon determining that an individual is eligible for an advanced premium tax credit
or cost-sharing reduction, the commissioner shall calculate the amount of the advanced
premium tax credit or the amount of the cost-sharing reduction, as provided under the
Affordable Care Act. The commissioner shall issue the individual with a certification form
that indicates the dollar value of the tax credit and the amount of any cost-sharing reduction.
new text end

new text begin (c) The commissioner shall also develop a method to make certification information
available electronically to insurance producers and health plan companies.
new text end

new text begin Subd. 4. new text end

new text begin Assessment of eligibility for medical assistance or MinnesotaCare. new text end

new text begin (a) The
commissioner shall assess applicant eligibility for medical assistance and MinnesotaCare.
To assess eligibility, the commissioner may access all necessary federal and state data
sources, including but not limited to the federal information technology platform.
new text end

new text begin (b) If the commissioner assesses an individual as eligible for coverage under medical
assistance or MinnesotaCare, the commissioner shall transmit all collected and verified
information to the commissioner of human services to enable the commissioner to make a
final determination of the individual's eligibility through county agencies. County agencies
shall make the final determination of eligibility using the county-based eligibility
determination system established under section 256.0145.
new text end

new text begin (c) An individual who is not assessed as eligible for medical assistance or MinnesotaCare
by the commissioner may still apply for coverage under these programs through the
appropriate county agency using the county-based eligibility determination system.
new text end

new text begin Subd. 5. new text end

new text begin Access to coverage using advanced premium tax credits. new text end

new text begin (a) An individual
determined to be eligible for an advanced premium tax credit or cost-sharing reduction may
present the certification form to an insurance producer or to a health plan company when
seeking qualified health plan coverage. An insurance producer or health plan company may
also access certification information electronically using the method developed by the
commissioner under subdivision 3.
new text end

new text begin (b) A health plan company shall adjust health plan premiums and cost-sharing for a
health plan to reflect any advanced premium tax credit or cost-sharing reduction to which
an individual is entitled based on the certification information provided.
new text end

new text begin Subd. 6. new text end

new text begin Appeals. new text end

new text begin The commissioner shall establish an appeals process for individuals
who are denied certification for an advanced premium tax credit or cost-sharing reduction.
new text end

new text begin Subd. 7. new text end

new text begin Vendor contract. new text end

new text begin The commissioner shall contract with a vendor to provide
technical assistance in implementing this section.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment, except
that subdivisions 3 to 6 are effective upon federal waiver approval. The commissioner of
human services shall notify the revisor of statutes when federal approval is obtained for
subdivisions 3 to 6.
new text end

Sec. 5. new text beginAPPROPRIATION.
new text end

new text begin $....... in fiscal year 2019 is appropriated from the general fund to the commissioner of
revenue to contract with a vendor for technical assistance in implementing Minnesota
Statutes, section 270C.031.
new text end

Sec. 6. new text begin REPEALER.
new text end

new text begin (a) new text end new text begin Minnesota Statutes 2016, sections 62V.01; 62V.02; 62V.03; 62V.04; 62V.05;
62V.051; 62V.055; 62V.06; 62V.07; 62V.08; 62V.09; 62V.10; and 62V.11, subdivisions
1, 2, 4, and 5,
new text end new text begin are repealed.
new text end

new text begin (b) new text end new text begin Minnesota Rules, parts 7700.0010; 7700.0020; 7700.0030; 7700.0040; 7700.0050;
7700.0060; 7700.0070; 7700.0080; 7700.0090; 7700.0100; 7700.0101; and 7700.0105,
new text end new text begin are
repealed.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective upon federal approval of the waiver
required under Minnesota Statutes, section 270C.031. The commissioner of human services
shall notify the revisor of statutes when federal approval is obtained.
new text end

ARTICLE 2

CONFORMING CHANGES

Section 1.

Minnesota Statutes 2016, section 62K.02, subdivision 1, is amended to read:


Subdivision 1.

Purpose.

The market rules set forth in this chapter serve to clarify and
provide guidance on the application of state law and certain requirements of the Affordable
Care Act on all health carriers offering health plans in Minnesotadeleted text begin, whether or not through
MNsure,
deleted text end to ensure fair competition for all health carriers in Minnesota, to minimize adverse
selection, and to ensure that health plans are offered in a manner that protects consumers
and promotes the provision of high-quality affordable health care, and improved health
outcomes. deleted text beginThis chapter contains the regulatory requirements as specified in section 62V.05,
subdivision 5
, paragraph (b), and shall fully satisfy the requirements of section 62V.05,
subdivision 5
, paragraph (b).
deleted text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective upon the effective date of article 1,
section 6. The commissioner of human services shall notify the revisor of statutes when this
occurs.
new text end

Sec. 2. new text beginREVISOR'S INSTRUCTION.
new text end

new text begin The revisor of statutes, in consultation with the House Research Department and Senate
Counsel, Research and Fiscal Analysis, shall prepare legislation that makes conforming
changes in accordance with the repealer in article 1, section 6. The revisor shall submit the
proposal, in a form ready for introduction, during the 2019 regular legislative session to the
chairs and ranking minority members of the senate and house of representatives committees
with jurisdiction over health care.
new text end

Sec. 3. new text begin REPEALER.
new text end

new text begin Minnesota Statutes 2016, sections 13.7191, subdivision 14a; 13D.08, subdivision 5a;
62A.011, subdivision 6; 62K.03, subdivision 9; and 256L.01, subdivision 6,
new text end new text begin are repealed.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective upon the effective date of article 1,
section 6. The commissioner of human services shall notify the revisor of statutes when this
occurs.
new text end

APPENDIX

Repealed Minnesota Statutes: 18-5510

13.7191 MISCELLANEOUS INSURANCE DATA CODED ELSEWHERE.

Subd. 14a.

MNsure.

Classification and sharing of data of MNsure is governed by section 62V.06.

13D.08 OPEN MEETING LAW CODED ELSEWHERE.

Subd. 5a.

MNsure.

Meetings of MNsure are governed by section 62V.03, subdivision 2.

62A.011 DEFINITIONS.

Subd. 6.

MNsure.

"MNsure" means MNsure as defined in section 62V.02.

62K.03 DEFINITIONS.

Subd. 9.

MNsure.

"MNsure" means MNsure as defined in section 62V.02.

62V.01 TITLE.

This chapter may be cited as the "MNsure Act."

62V.02 DEFINITIONS.

Subdivision 1.

Scope.

For the purposes of this chapter, the following terms have the meanings given.

Subd. 2.

Board.

"Board" means the Board of Directors of MNsure specified in section 62V.04.

Subd. 3.

Dental plan.

"Dental plan" has the meaning defined in section 62Q.76, subdivision 3.

Subd. 4.

Health plan.

"Health plan" means a policy, contract, certificate, or agreement defined in section 62A.011, subdivision 3.

Subd. 5.

Health carrier.

"Health carrier" has the meaning defined in section 62A.011.

Subd. 6.

Individual market.

"Individual market" means the market for health insurance coverage offered to individuals.

Subd. 7.

Insurance producer.

"Insurance producer" has the meaning defined in section 60K.31.

Subd. 8.

MNsure.

"MNsure" means the state health benefit exchange as described in section 1311 of the federal Patient Protection and Affordable Care Act, Public Law 111-148, and further defined through amendments to the act and regulations issued under the act.

Subd. 9.

Navigator.

"Navigator" has the meaning described in section 1311(i) of the federal Patient Protection and Affordable Care Act, Public Law 111-148, and further defined through amendments to the act and regulations issued under the act.

Subd. 10.

Public health care program.

"Public health care program" means any public health care program administered by the commissioner of human services.

Subd. 11.

Qualified health plan.

"Qualified health plan" means a health plan that meets the definition in section 1301(a) of the Affordable Care Act, Public Law 111-148, and has been certified by the board in accordance with section 62V.05, subdivision 5, to be offered through MNsure.

Subd. 12.

Small group market.

"Small group market" means the market for health insurance coverage offered to small employers as defined in section 62L.02, subdivision 26.

Subd. 13.

Web site.

"Web site" means a site maintained on the World Wide Web by MNsure that allows for access to information and services provided by MNsure.

62V.03 MNSURE; ESTABLISHMENT.

Subdivision 1.

Creation.

MNsure is created as a board under section 15.012, paragraph (a), to:

(1) promote informed consumer choice, innovation, competition, quality, value, market participation, affordability, suitable and meaningful choices, health improvement, care management, reduction of health disparities, and portability of health plans;

(2) facilitate and simplify the comparison, choice, enrollment, and purchase of health plans for individuals purchasing in the individual market through MNsure and for employees and employers purchasing in the small group market through MNsure;

(3) assist small employers with access to small business health insurance tax credits and to assist individuals with access to public health care programs, premium assistance tax credits and cost-sharing reductions, and certificates of exemption from individual responsibility requirements;

(4) facilitate the integration and transition of individuals between public health care programs and health plans in the individual or group market and develop processes that, to the maximum extent possible, provide for continuous coverage; and

(5) establish and modify as necessary a name and brand for MNsure based on market studies that show maximum effectiveness in attracting the uninsured and motivating them to take action.

Subd. 2.

Application of other law.

(a) MNsure must be reviewed by the legislative auditor under section 3.971. The legislative auditor shall audit the books, accounts, and affairs of MNsure once each year or less frequently as the legislative auditor's funds and personnel permit. Upon the audit of the financial accounts and affairs of MNsure, MNsure is liable to the state for the total cost and expenses of the audit, including the salaries paid to the examiners while actually engaged in making the examination. The legislative auditor may bill MNsure either monthly or at the completion of the audit. All collections received for the audits must be deposited in the general fund and are appropriated to the legislative auditor. Pursuant to section 3.97, subdivision 3a, the Legislative Audit Commission is requested to direct the legislative auditor to report by March 1, 2014, to the legislature on any duplication of services that occurs within state government as a result of the creation of MNsure. The legislative auditor may make recommendations on consolidating or eliminating any services deemed duplicative. The board shall reimburse the legislative auditor for any costs incurred in the creation of this report.

(b) Board members of MNsure are subject to sections 10A.07 and 10A.09. Board members and the personnel of MNsure are subject to section 10A.071.

(c) All meetings of the board and of the Minnesota Eligibility System Executive Steering Committee established under section 62V.055 shall comply with the open meeting law in chapter 13D.

(d) The board and the Web site are exempt from chapter 60K. Any employee of MNsure who sells, solicits, or negotiates insurance to individuals or small employers must be licensed as an insurance producer under chapter 60K.

(e) Section 3.3005 applies to any federal funds received by MNsure.

(f) A MNsure decision that requires a vote of the board, other than a decision that applies only to hiring of employees or other internal management of MNsure, is an "administrative action" under section 10A.01, subdivision 2.

Subd. 3.

Continued operation of a private marketplace.

(a) Nothing in this chapter shall be construed to prohibit: (1) a health carrier from offering outside of MNsure a health plan to a qualified individual or qualified employer; and (2) a qualified individual from enrolling in, or a qualified employer from selecting for its employees, a health plan offered outside of MNsure.

(b) Nothing in this chapter shall be construed to restrict the choice of a qualified individual to enroll or not enroll in a qualified health plan or to participate in MNsure. Nothing in this chapter shall be construed to compel an individual to enroll in a qualified health plan or to participate in MNsure.

(c) For purposes of this subdivision, "qualified individual" and "qualified employer" have the meanings given in section 1312 of the Affordable Care Act, Public Law 111-148, and further defined through amendments to the act and regulations issued under the act.

62V.04 GOVERNANCE.

Subdivision 1.

Board.

MNsure is governed by a board of directors with seven members.

Subd. 2.

Appointment.

(a) Board membership of MNsure consists of the following:

(1) three members appointed by the governor with the advice and consent of both the senate and the house of representatives acting separately in accordance with paragraph (d), with one member representing the interests of individual consumers eligible for individual market coverage, one member representing individual consumers eligible for public health care program coverage, and one member representing small employers. Members are appointed to serve four-year terms following the initial staggered-term lot determination;

(2) three members appointed by the governor with the advice and consent of both the senate and the house of representatives acting separately in accordance with paragraph (d) who have demonstrated expertise, leadership, and innovation in the following areas: one member representing the areas of health administration, health care finance, health plan purchasing, and health care delivery systems; one member representing the areas of public health, health disparities, public health care programs, and the uninsured; and one member representing health policy issues related to the small group and individual markets. Members are appointed to serve four-year terms following the initial staggered-term lot determination; and

(3) the commissioner of human services or a designee.

(b) Section 15.0597 shall apply to all appointments, except for the commissioner.

(c) The governor shall make appointments to the board that are consistent with federal law and regulations regarding its composition and structure. All board members appointed by the governor must be legal residents of Minnesota.

(d) Upon appointment by the governor, a board member shall exercise duties of office immediately. If both the house of representatives and the senate vote not to confirm an appointment, the appointment terminates on the day following the vote not to confirm in the second body to vote.

(e) Initial appointments shall be made by April 30, 2013.

(f) One of the six members appointed under paragraph (a), clause (1) or (2), must have experience in representing the needs of vulnerable populations and persons with disabilities.

(g) Membership on the board must include representation from outside the seven-county metropolitan area, as defined in section 473.121, subdivision 2.

Subd. 3.

Terms.

(a) Board members may serve no more than two consecutive terms, except for the commissioner or the commissioner's designee, who shall serve until replaced by the governor.

(b) A board member may resign at any time by giving written notice to the board.

(c) The appointed members under subdivision 2, paragraph (a), clauses (1) and (2), shall have an initial term of two, three, or four years, determined by lot by the secretary of state.

Subd. 4.

Conflicts of interest.

(a) Within one year prior to or at any time during their appointed term, board members appointed under subdivision 2, paragraph (a), clauses (1) and (2), shall not be employed by, be a member of the board of directors of, or otherwise be a representative of a health carrier, institutional health care provider or other entity providing health care, navigator, insurance producer, or other entity in the business of selling items or services of significant value to or through MNsure. For purposes of this paragraph, "health care provider or entity" does not include an academic institution.

(b) Board members must recuse themselves from discussion of and voting on an official matter if the board member has a conflict of interest. A conflict of interest means an association including a financial or personal association that has the potential to bias or have the appearance of biasing a board member's decisions in matters related to MNsure or the conduct of activities under this chapter.

(c) No board member shall have a spouse who is an executive of a health carrier.

(d) No member of the board may currently serve as a lobbyist, as defined under section 10A.01, subdivision 21.

Subd. 5.

Acting chair; first meeting; supervision.

(a) The governor shall designate as acting chair one of the appointees described in subdivision 2.

(b) The board shall hold its first meeting within 60 days of enactment.

(c) The board shall elect a chair to replace the acting chair at the first meeting.

Subd. 6.

Chair.

The board shall have a chair, elected by a majority of members. The chair shall serve for one year.

Subd. 7.

Officers.

The members of the board shall elect officers by a majority of members. The officers shall serve for one year.

Subd. 8.

Vacancies.

If a vacancy occurs, the governor shall appoint a new member within 90 days, and the newly appointed member shall be subject to the same confirmation process described in subdivision 2.

Subd. 9.

Removal.

(a) A board member may be removed by the appointing authority and a majority vote of the board following notice and hearing before the board. For purposes of this subdivision, the appointing authority or a designee of the appointing authority shall be a voting member of the board for purposes of constituting a quorum.

(b) A conflict of interest as defined in subdivision 4, shall be cause for removal from the board.

Subd. 10.

Meetings.

The board shall meet at least quarterly.

Subd. 11.

Quorum.

A majority of the members of the board constitutes a quorum, and the affirmative vote of a majority of members of the board is necessary and sufficient for action taken by the board.

Subd. 12.

Compensation.

(a) The board members shall be paid a salary not to exceed the salary limits established under section 15A.0815, subdivision 4. The salary for board members shall be set in accordance with this subdivision and section 15A.0815, subdivision 5. This paragraph expires December 31, 2015.

(b) Beginning January 1, 2016, the board members may be compensated in accordance with section 15.0575.

Subd. 13.

Advisory committees.

(a) The board shall establish and maintain advisory committees to provide insurance producers, health care providers, the health care industry, consumers, and other stakeholders with the opportunity to advise the board regarding the operation of MNsure as required under section 1311(d)(6) of the Affordable Care Act, Public Law 111-148. The board shall regularly consult with the advisory committees. The advisory committees established under this paragraph shall not expire.

(b) The board may establish additional advisory committees, as necessary, to gather and provide information to the board in order to facilitate the operation of MNsure. The advisory committees established under this paragraph shall not expire, except by action of the board.

(c) Section 15.0597 shall not apply to any advisory committee established by the board under this subdivision.

(d) The board may provide compensation and expense reimbursement under section 15.059, subdivision 3, to members of the advisory committees.

62V.05 RESPONSIBILITIES AND POWERS OF MNSURE.

Subdivision 1.

General.

(a) The board shall operate MNsure according to this chapter and applicable state and federal law.

(b) The board has the power to:

(1) employ personnel and delegate administrative, operational, and other responsibilities to the director and other personnel as deemed appropriate by the board. This authority is subject to chapters 43A and 179A. The director and managerial staff of MNsure shall serve in the unclassified service and shall be governed by a compensation plan prepared by the board, submitted to the commissioner of management and budget for review and comment within 14 days of its receipt, and approved by the Legislative Coordinating Commission and the legislature under section 3.855, except that section 15A.0815, subdivision 5, paragraph (e), shall not apply;

(2) establish the budget of MNsure;

(3) seek and accept money, grants, loans, donations, materials, services, or advertising revenue from government agencies, philanthropic organizations, and public and private sources to fund the operation of MNsure. No health carrier or insurance producer shall advertise on MNsure;

(4) contract for the receipt and provision of goods and services;

(5) enter into information-sharing agreements with federal and state agencies and other entities, provided the agreements include adequate protections with respect to the confidentiality and integrity of the information to be shared, and comply with all applicable state and federal laws, regulations, and rules, including the requirements of section 62V.06; and

(6) exercise all powers reasonably necessary to implement and administer the requirements of this chapter and the Affordable Care Act, Public Law 111-148.

(c) The board shall establish policies and procedures to gather public comment and provide public notice in the State Register.

(d) Within 180 days of enactment, the board shall establish bylaws, policies, and procedures governing the operations of MNsure in accordance with this chapter.

Subd. 2.

Operations funding.

(a) Prior to January 1, 2015, MNsure shall retain or collect up to 1.5 percent of total premiums for individual and small group market health plans and dental plans sold through MNsure to fund the cash reserves of MNsure, but the amount collected shall not exceed a dollar amount equal to 25 percent of the funds collected under section 62E.11, subdivision 6, for calendar year 2012.

(b) Beginning January 1, 2015, MNsure shall retain or collect up to 3.5 percent of total premiums for individual and small group market health plans and dental plans sold through MNsure to fund the operations of MNsure, but the amount collected shall not exceed a dollar amount equal to 50 percent of the funds collected under section 62E.11, subdivision 6, for calendar year 2012.

(c) Beginning January 1, 2016, MNsure shall retain or collect up to 3.5 percent of total premiums for individual and small group market health plans and dental plans sold through MNsure to fund the operations of MNsure, but the amount collected may never exceed a dollar amount greater than 100 percent of the funds collected under section 62E.11, subdivision 6, for calendar year 2012.

(d) For fiscal years 2014 and 2015, the commissioner of management and budget is authorized to provide cash flow assistance of up to $20,000,000 from the special revenue fund or the statutory general fund under section 16A.671, subdivision 3, paragraph (a), to MNsure. Any funds provided under this paragraph shall be repaid, with interest, by June 30, 2015.

(e) Funding for the operations of MNsure shall cover any compensation provided to navigators participating in the navigator program.

Subd. 3.

Insurance producers.

(a) By April 30, 2013, the board, in consultation with the commissioner of commerce, shall establish certification requirements that must be met by insurance producers in order to assist individuals and small employers with purchasing coverage through MNsure. Prior to January 1, 2015, the board may amend the requirements, only if necessary, due to a change in federal rules.

(b) Certification requirements shall not exceed the requirements established under Code of Federal Regulations, title 45, part 155.220. Certification shall include training on health plans available through MNsure, available tax credits and cost-sharing arrangements, compliance with privacy and security standards, eligibility verification processes, online enrollment tools, and basic information on available public health care programs. Training required for certification under this subdivision shall qualify for continuing education requirements for insurance producers required under chapter 60K, and must comply with course approval requirements under chapter 45.

(c) Producer compensation shall be established by health carriers that provide health plans through MNsure. The structure of compensation to insurance producers must be similar for health plans sold through MNsure and outside MNsure.

(d) Any insurance producer compensation structure established by a health carrier for the small group market must include compensation for defined contribution plans that involve multiple health carriers. The compensation offered must be commensurate with other small group market defined health plans.

(e) Any insurance producer assisting an individual or small employer with purchasing coverage through MNsure must disclose, orally and in writing, to the individual or small employer at the time of the first solicitation with the prospective purchaser the following:

(1) the health carriers and qualified health plans offered through MNsure that the producer is authorized to sell, and that the producer may not be authorized to sell all the qualified health plans offered through MNsure;

(2) that the producer may be receiving compensation from a health carrier for enrolling the individual or small employer into a particular health plan; and

(3) that information on all qualified health plans offered through MNsure is available through the MNsure Web site.

For purposes of this paragraph, "solicitation" means any contact by a producer, or any person acting on behalf of a producer made for the purpose of selling or attempting to sell coverage through MNsure. If the first solicitation is made by telephone, the disclosures required under this paragraph need not be made in writing, but the fact that disclosure has been made must be acknowledged on the application.

(f) Beginning January 15, 2015, each health carrier that offers or sells qualified health plans through MNsure shall report in writing to the board and the commissioner of commerce the compensation and other incentives it offers or provides to insurance producers with regard to each type of health plan the health carrier offers or sells both inside and outside of MNsure. Each health carrier shall submit a report annually and upon any change to the compensation or other incentives offered or provided to insurance producers.

(g) Nothing in this chapter shall prohibit an insurance producer from offering professional advice and recommendations to a small group purchaser based upon information provided to the producer.

(h) An insurance producer that offers health plans in the small group market shall notify each small group purchaser of which group health plans qualify for Internal Revenue Service approved section 125 tax benefits. The insurance producer shall also notify small group purchasers of state law provisions that benefit small group plans when the employer agrees to pay 50 percent or more of its employees' premium. Individuals who are eligible for cost-effective medical assistance will count toward the 75 percent participation requirement in section 62L.03, subdivision 3.

(i) Nothing in this subdivision shall be construed to limit the licensure requirements or regulatory functions of the commissioner of commerce under chapter 60K.

Subd. 4.

Navigator; in-person assisters; call center.

(a) The board shall establish policies and procedures for the ongoing operation of a navigator program, in-person assister program, call center, and customer service provisions for MNsure to be implemented beginning January 1, 2015.

(b) Until the implementation of the policies and procedures described in paragraph (a), the following shall be in effect:

(1) the navigator program shall be met by section 256.962;

(2) entities eligible to be navigators, including entities defined in Code of Federal Regulations, title 45, part 155.210 (c)(2), may serve as in-person assisters;

(3) the board shall establish requirements and compensation for the navigator program and the in-person assister program by April 30, 2013. Compensation for navigators and in-person assisters must take into account any other compensation received by the navigator or in-person assister for conducting the same or similar services; and

(4) call center operations shall utilize existing state resources and personnel, including referrals to counties for medical assistance.

(c) The board shall establish a toll-free number for MNsure and may hire and contract for additional resources as deemed necessary.

(d) The navigator program and in-person assister program must meet the requirements of section 1311(i) of the Affordable Care Act, Public Law 111-148. In establishing training standards for the navigators and in-person assisters, the board must ensure that all entities and individuals carrying out navigator and in-person assister functions have training in the needs of underserved and vulnerable populations; eligibility and enrollment rules and procedures; the range of available public health care programs and qualified health plan options offered through MNsure; and privacy and security standards. For calendar year 2014, the commissioner of human services shall ensure that the navigator program under section 256.962 provides application assistance for both qualified health plans offered through MNsure and public health care programs.

(e) The board must ensure that any information provided by navigators, in-person assisters, the call center, or other customer assistance portals be accessible to persons with disabilities and that information provided on public health care programs include information on other coverage options available to persons with disabilities.

Subd. 5.

Health carrier and health plan requirements; participation.

(a) Beginning January 1, 2015, the board may establish certification requirements for health carriers and health plans to be offered through MNsure that satisfy federal requirements under section 1311(c)(1) of the Affordable Care Act, Public Law 111-148.

(b) Paragraph (a) does not apply if by June 1, 2013, the legislature enacts regulatory requirements that:

(1) apply uniformly to all health carriers and health plans in the individual market;

(2) apply uniformly to all health carriers and health plans in the small group market; and

(3) satisfy minimum federal certification requirements under section 1311(c)(1) of the Affordable Care Act, Public Law 111-148.

(c) In accordance with section 1311(e) of the Affordable Care Act, Public Law 111-148, the board shall establish policies and procedures for certification and selection of health plans to be offered as qualified health plans through MNsure. The board shall certify and select a health plan as a qualified health plan to be offered through MNsure, if:

(1) the health plan meets the minimum certification requirements established in paragraph (a) or the market regulatory requirements in paragraph (b);

(2) the board determines that making the health plan available through MNsure is in the interest of qualified individuals and qualified employers;

(3) the health carrier applying to offer the health plan through MNsure also applies to offer health plans at each actuarial value level and service area that the health carrier currently offers in the individual and small group markets; and

(4) the health carrier does not apply to offer health plans in the individual and small group markets through MNsure under a separate license of a parent organization or holding company under section 60D.15, that is different from what the health carrier offers in the individual and small group markets outside MNsure.

(d) In determining the interests of qualified individuals and employers under paragraph (c), clause (2), the board may not exclude a health plan for any reason specified under section 1311(e)(1)(B) of the Affordable Care Act, Public Law 111-148. The board may consider:

(1) affordability;

(2) quality and value of health plans;

(3) promotion of prevention and wellness;

(4) promotion of initiatives to reduce health disparities;

(5) market stability and adverse selection;

(6) meaningful choices and access;

(7) alignment and coordination with state agency and private sector purchasing strategies and payment reform efforts; and

(8) other criteria that the board determines appropriate.

(e) For qualified health plans offered through MNsure on or after January 1, 2015, the board shall establish policies and procedures under paragraphs (c) and (d) for selection of health plans to be offered as qualified health plans through MNsure by February 1 of each year, beginning February 1, 2014. The board shall consistently and uniformly apply all policies and procedures and any requirements, standards, or criteria to all health carriers and health plans. For any policies, procedures, requirements, standards, or criteria that are defined as rules under section 14.02, subdivision 4, the board may use the process described in subdivision 9.

(f) For 2014, the board shall not have the power to select health carriers and health plans for participation in MNsure. The board shall permit all health plans that meet the certification requirements under section 1311(c)(1) of the Affordable Care Act, Public Law 111-148, to be offered through MNsure.

(g) Under this subdivision, the board shall have the power to verify that health carriers and health plans are properly certified to be eligible for participation in MNsure.

(h) The board has the authority to decertify health carriers and health plans that fail to maintain compliance with section 1311(c)(1) of the Affordable Care Act, Public Law 111-148.

(i) For qualified health plans offered through MNsure beginning January 1, 2015, health carriers must use the most current addendum for Indian health care providers approved by the Centers for Medicare and Medicaid Services and the tribes as part of their contracts with Indian health care providers. MNsure shall comply with all future changes in federal law with regard to health coverage for the tribes.

Subd. 6.

Appeals.

(a) The board may conduct hearings, appoint hearing officers, and recommend final orders related to appeals of any MNsure determinations, except for those determinations identified in paragraph (d). An appeal by a health carrier regarding a specific certification or selection determination made by MNsure under subdivision 5 must be conducted as a contested case proceeding under chapter 14, with the report or order of the administrative law judge constituting the final decision in the case, subject to judicial review under sections 14.63 to 14.69. For other appeals, the board shall establish hearing processes which provide for a reasonable opportunity to be heard and timely resolution of the appeal and which are consistent with the requirements of federal law and guidance. An appealing party may be represented by legal counsel at these hearings, but this is not a requirement.

(b) MNsure may establish service-level agreements with state agencies to conduct hearings for appeals. Notwithstanding section 471.59, subdivision 1, a state agency is authorized to enter into service-level agreements for this purpose with MNsure.

(c) For proceedings under this subdivision, MNsure may be represented by an attorney who is an employee of MNsure.

(d) This subdivision does not apply to appeals of determinations where a state agency hearing is available under section 256.045.

(e) An appellant aggrieved by an order of MNsure issued in an eligibility appeal, as defined in Minnesota Rules, part 7700.0101, may appeal the order to the district court of the appellant's county of residence by serving a written copy of a notice of appeal upon MNsure and any other adverse party of record within 30 days after the date MNsure issued the order, the amended order, or order affirming the original order, and by filing the original notice and proof of service with the court administrator of the district court. Service may be made personally or by mail; service by mail is complete upon mailing; no filing fee shall be required by the court administrator in appeals taken pursuant to this subdivision. MNsure shall furnish all parties to the proceedings with a copy of the decision and a transcript of any testimony, evidence, or other supporting papers from the hearing held before the appeals examiner within 45 days after service of the notice of appeal.

(f) Any party aggrieved by the failure of an adverse party to obey an order issued by MNsure may compel performance according to the order in the manner prescribed in sections 586.01 to 586.12.

(g) Any party may obtain a hearing at a special term of the district court by serving a written notice of the time and place of the hearing at least ten days prior to the date of the hearing. The court may consider the matter in or out of chambers, and shall take no new or additional evidence unless it determines that such evidence is necessary for a more equitable disposition of the appeal.

(h) Any party aggrieved by the order of the district court may appeal the order as in other civil cases. No costs or disbursements shall be taxed against any party nor shall any filing fee or bond be required of any party.

(i) If MNsure or district court orders eligibility for qualified health plan coverage through MNsure, or eligibility for federal advance payment of premium tax credits or cost-sharing reductions contingent upon full payment of respective premiums, the premiums must be paid or provided pending appeal to the district court, Court of Appeals, or Supreme Court. Provision of eligibility by MNsure pending appeal does not render moot MNsure's position in a court of law.

Subd. 7.

Agreements; consultation.

(a) The board shall:

(1) establish and maintain an agreement with the commissioner of human services for cost allocation and services regarding eligibility determinations and enrollment for public health care programs that use a modified adjusted gross income standard to determine program eligibility. The board may establish and maintain an agreement with the commissioner of human services for other services;

(2) establish and maintain an agreement with the commissioners of commerce and health for services regarding enforcement of MNsure certification requirements for health plans and dental plans offered through MNsure. The board may establish and maintain agreements with the commissioners of commerce and health for other services; and

(3) establish interagency agreements to transfer funds to other state agencies for their costs related to implementing and operating MNsure, excluding medical assistance allocatable costs.

(b) The board shall consult with the commissioners of commerce and health regarding the operations of MNsure.

(c) The board shall consult with Indian tribes and organizations regarding the operation of MNsure.

(d) Beginning March 15, 2016, and each March 15 thereafter, the board shall submit a report to the chairs and ranking minority members of the committees in the senate and house of representatives with primary jurisdiction over commerce, health, and human services on all the agreements entered into with the chief information officer of the Office of MN.IT Services, or the commissioners of human services, health, or commerce in accordance with this subdivision. The report shall include the agency in which the agreement is with; the time period of the agreement; the purpose of the agreement; and a summary of the terms of the agreement. A copy of the agreement must be submitted to the extent practicable.

Subd. 8.

Rulemaking.

The board may adopt rules to implement any provisions in this chapter using the expedited rulemaking process in section 14.389.

Subd. 9.

Dental plans.

(a) The provisions of this section that apply to health plans shall apply to dental plans offered as stand-alone dental plans through MNsure, to the extent practicable.

(b) A stand-alone dental plan offered through MNsure must meet all certification requirements under section 1311(c)(1) of the Affordable Care Act, Public Law 111-148, that are applicable to health plans, except for certification requirements that cannot be met because the dental plan only covers dental benefits.

Subd. 10.

Limitations; risk-bearing.

(a) The board shall not bear insurance risk or enter into any agreement with health care providers to pay claims.

(b) Nothing in this subdivision shall prevent MNsure from providing insurance for its employees.

Subd. 11.

Prohibition on other product lines.

MNsure is prohibited from certifying, selecting, or offering products and policies of coverage that do not meet the definition of health plan or dental plan as provided in section 62V.02.

Subd. 12.

Reports on interagency agreements and intra-agency transfers.

The MNsure Board shall provide quarterly reports to the chairs and ranking minority members of the legislative committees with jurisdiction over health and human services policy and finance on:

(1) interagency agreements or service-level agreements and any renewals or extensions of existing interagency or service-level agreements with a state department under section 15.01, state agency under section 15.012, or the Office of MN.IT Services, with a value of more than $100,000, or related agreements with the same department or agency with a cumulative value of more than $100,000; and

(2) transfers of appropriations of more than $100,000 between accounts within or between agencies.

The report must include the statutory citation authorizing the agreement, transfer or dollar amount, purpose, and effective date of the agreement, the duration of the agreement, and a copy of the agreement.

62V.051 MNSURE; CONSUMER RETROACTIVE APPOINTMENT OF A NAVIGATOR OR PRODUCER PERMITTED.

Notwithstanding any other law or rule to the contrary, for up to six months after the effective date of the qualified health plan, MNsure must permit a qualified health plan policyholder, who has not designated a navigator or an insurance producer, to retroactively appoint a navigator or insurance producer. MNsure must provide notice of the retroactive appointment to the health carrier. The health carrier must retroactively pay commissions to the insurance producer if the producer can demonstrate that they were certified by MNsure at the time of the original enrollment, were appointed by the selected health carrier at the time of the enrollment, and that an agent of record agreement was executed prior to or at the time of the effective date of the policy. MNsure must adopt a standard form of agent of record agreement for purposes of this section.

62V.055 MINNESOTA ELIGIBILITY SYSTEM EXECUTIVE STEERING COMMITTEE.

Subdivision 1.

Definition; Minnesota eligibility system.

For purposes of this section, "Minnesota eligibility system" means the system that supports eligibility determinations using a modified adjusted gross income methodology for medical assistance under section 256B.056, subdivision 1a, paragraph (b), clause (1); MinnesotaCare under chapter 256L; and qualified health plan enrollment under section 62V.05, subdivision 5, paragraph (c).

Subd. 2.

Establishment; committee membership; costs.

(a) The Minnesota Eligibility System Executive Steering Committee is established to provide recommendations to the MNsure board, the commissioner of human services, and the commissioner of MN.IT services on the governance, administration, and business operations of the Minnesota eligibility system. The steering committee shall be composed of:

(1) two members appointed by the commissioner of human services;

(2) two members appointed by the board;

(3) two members appointed jointly by the Association of Minnesota Counties, the Minnesota Inter-County Association, and the Minnesota Association of County Social Service Administrators. One member appointed under this clause shall represent counties within the seven-county metropolitan area, and one member shall represent counties outside the seven-county metropolitan area; and

(4) two nonvoting members appointed by the commissioner of MN.IT services.

(b) One member appointed by the commissioner of human services and one member appointed by the commissioner of MN.IT services shall serve as co-chairpersons for the steering committee.

(c) Steering committee costs must be paid from the budgets of the Department of Human Services, the Office of MN.IT Services, and MNsure.

Subd. 3.

Duties.

The Minnesota Eligibility System Executive Steering Committee shall provide recommendations on an overall governance structure for the Minnesota eligibility system and the ongoing administration and business operations of the Minnesota eligibility system. The steering committee shall make recommendations on setting system goals and priorities, allocating the system's resources, making major system decisions, and tracking total funding and expenditures for the system from all sources. The steering committee shall also report to the Legislative Oversight Committee on a quarterly basis on Minnesota eligibility system funding and expenditures, including amounts received in the most recent quarter by funding source and expenditures made in the most recent quarter by funding source.

Subd. 4.

Meetings.

(a) All meetings of the steering committee must:

(1) be held in the State Office Building, the Minnesota Senate Building, or when approved by the Legislative Oversight Committee, another public location with the capacity to live stream steering committee meetings; and

(2) whenever possible, be made available on a Web site for live audio or video streaming and be archived on a Web site for playback at a later time.

(b) The steering committee must:

(1) as part of every steering committee meeting, provide the opportunity for oral and written public testimony and comments on steering committee recommendations for the governance, administration, and business operations of the Minnesota eligibility system; and

(2) provide documents under discussion or review by the steering committee to be electronically posted on MNsure's Web site. Documents must be provided and posted prior to the meeting at which the documents are scheduled for review or discussion.

(c) All votes of the steering committee must be recorded, with each member's vote identified.

Subd. 5.

Administrative structure.

The Office of MN.IT Services shall be responsible for the design, build, maintenance, operation, and upgrade of the information technology for the Minnesota eligibility system. In carrying out its duties, the office shall consider recommendations made by the steering committee.

62V.06 DATA PRACTICES.

Subdivision 1.

Applicability.

MNsure is a state agency for purposes of the Minnesota Government Data Practices Act and is subject to all provisions of chapter 13, in addition to the requirements contained in this section.

Subd. 2.

Definitions.

As used in this section:

(1) "individual" means an individual according to section 13.02, subdivision 8, but does not include a vendor of services; and

(2) "participating" means that an individual, employee, or employer is seeking, or has sought an eligibility determination, enrollment processing, or premium processing through MNsure.

Subd. 3.

General data classifications.

The following data collected, created, or maintained by MNsure are classified as private data on individuals, as defined in section 13.02, subdivision 12, or nonpublic data, as defined in section 13.02, subdivision 9:

(1) data on any individual participating in MNsure;

(2) data on any individuals participating in MNsure as employees of an employer participating in MNsure; and

(3) data on employers participating in MNsure.

Subd. 4.

Application and certification data.

(a) Data submitted by an insurance producer in an application for certification to sell a health plan through MNsure, or submitted by an applicant seeking permission or a commission to act as a navigator or in-person assister, are classified as follows:

(1) at the time the application is submitted, all data contained in the application are private data, as defined in section 13.02, subdivision 12, or nonpublic data as defined in section 13.02, subdivision 9, except that the name of the applicant is public; and

(2) upon a final determination related to the application for certification by MNsure, all data contained in the application are public, with the exception of trade secret data as defined in section 13.37.

(b) Data created or maintained by a government entity as part of the evaluation of an application are protected nonpublic data, as defined in section 13.02, subdivision 13, until a final determination as to certification is made and all rights of appeal have been exhausted. Upon a final determination and exhaustion of all rights of appeal, these data are public, with the exception of trade secret data as defined in section 13.37 and data subject to attorney-client privilege or other protection as provided in section 13.393.

(c) If an application is denied, the public data must include the criteria used by the board to evaluate the application and the specific reasons for the denial, and these data must be published on the MNsure Web site.

Subd. 5.

Data sharing.

(a) MNsure may share or disseminate data classified as private or nonpublic in subdivision 3 as follows:

(1) to the subject of the data, as provided in section 13.04;

(2) according to a court order;

(3) according to a state or federal law specifically authorizing access to the data;

(4) with other state or federal agencies, only to the extent necessary to verify the identity of, determine the eligibility of, process premiums for, process enrollment of, or investigate fraud related to an individual, employer, or employee participating in MNsure, provided that MNsure must enter into a data-sharing agreement with the agency prior to sharing data under this clause; and

(5) with a nongovernmental person or entity, only to the extent necessary to verify the identity of, determine the eligibility of, process premiums for, process enrollment of, or investigate fraud related to an individual, employer, or employee participating in MNsure, provided that MNsure must enter into a contract with the person or entity, as provided in section 13.05, subdivision 6 or 11, prior to disseminating data under this clause.

(b) MNsure may share or disseminate data classified as private or nonpublic in subdivision 4 as follows:

(1) to the subject of the data, as provided in section 13.04;

(2) according to a court order;

(3) according to a state or federal law specifically authorizing access to the data;

(4) with other state or federal agencies, only to the extent necessary to carry out the functions of MNsure, provided that MNsure must enter into a data-sharing agreement with the agency prior to sharing data under this clause; and

(5) with a nongovernmental person or entity, only to the extent necessary to carry out the functions of MNsure, provided that MNsure must enter a contract with the person or entity, as provided in section 13.05, subdivision 6 or 11, prior to disseminating data under this clause.

(c) Sharing or disseminating data outside of MNsure in a manner not authorized by this subdivision is prohibited. The list of authorized dissemination and sharing contained in this subdivision must be included in the Tennessen warning required by section 13.04, subdivision 2.

(d) Until July 1, 2014, state agencies must share data classified as private or nonpublic on individuals, employees, or employers participating in MNsure with MNsure, only to the extent such data are necessary to verify the identity of, determine the eligibility of, process premiums for, process enrollment of, or investigate fraud related to a MNsure participant. The agency must enter into a data-sharing agreement with MNsure prior to sharing any data under this paragraph.

Subd. 6.

Notice and disclosures.

(a) In addition to the Tennessen warning required by section 13.04, subdivision 2, MNsure must provide any data subject asked to supply private data with:

(1) a notice of rights related to the handling of genetic information, pursuant to section 13.386; and

(2) a notice of the records retention policy of MNsure, detailing the length of time MNsure will retain data on the individual and the manner in which it will be destroyed upon expiration of that time.

(b) All notices required by this subdivision, including the Tennessen warning, must be provided in an electronic format suitable for downloading or printing.

Subd. 7.

Summary data.

In addition to creation and disclosure of summary data derived from private data on individuals, as permitted by section 13.05, subdivision 7, MNsure may create and disclose summary data derived from data classified as nonpublic under this section.

Subd. 8.

Access to data; audit trail.

(a) Only individuals with explicit authorization from the board may enter, update, or access not public data collected, created, or maintained by MNsure. The ability of authorized individuals to enter, update, or access data must be limited through the use of role-based access that corresponds to the official duties or training level of the individual, and the statutory authorization that grants access for that purpose. All queries and responses, and all actions in which data are entered, updated, accessed, or shared or disseminated outside of MNsure, must be recorded in a data audit trail. Data contained in the audit trail are public, to the extent that the data are not otherwise classified by this section.

The board shall immediately and permanently revoke the authorization of any individual determined to have willfully entered, updated, accessed, shared, or disseminated data in violation of this section, or any provision of chapter 13. If an individual is determined to have willfully gained access to data without explicit authorization from the board, the board shall forward the matter to the county attorney for prosecution.

(b) This subdivision shall not limit or affect the authority of the legislative auditor to access data needed to conduct audits, evaluations, or investigations of MNsure or the obligation of the board and MNsure employees to comply with section 3.978, subdivision 2.

(c) This subdivision does not apply to actions taken by a MNsure participant to enter, update, or access data held by MNsure, if the participant is the subject of the data that is entered, updated, or accessed.

Subd. 9.

Sale of data prohibited.

MNsure may not sell any data collected, created, or maintained by MNsure, regardless of its classification, for commercial or any other purposes.

Subd. 10.

Gun and firearm ownership.

MNsure shall not collect information that indicates whether or not an individual owns a gun or has a firearm in the individual's home.

62V.07 FUNDS.

(a) The MNsure account is created in the special revenue fund of the state treasury. All funds received by MNsure shall be deposited in the account. Funds in the account are appropriated to MNsure for the operation of MNsure. Notwithstanding section 11A.20, all investment income and all investment losses attributable to the investment of the MNsure account not currently needed, shall be credited to the MNsure account.

(b) The budget submitted to the legislature under section 16A.11 must include budget information for MNsure.

62V.08 REPORTS.

(a) MNsure shall submit a report to the legislature by January 15, 2015, and each January 15 thereafter, on: (1) the performance of MNsure operations; (2) meeting MNsure responsibilities; (3) an accounting of MNsure budget activities; (4) practices and procedures that have been implemented to ensure compliance with data practices laws, and a description of any violations of data practices laws or procedures; and (5) the effectiveness of the outreach and implementation activities of MNsure in reducing the rate of uninsurance.

(b) MNsure must publish its administrative and operational costs on a Web site to educate consumers on those costs. The information published must include: (1) the amount of premiums and federal premium subsidies collected; (2) the amount and source of revenue received under section 62V.05, subdivision 1, paragraph (b), clause (3); (3) the amount and source of any other fees collected for purposes of supporting operations; and (4) any misuse of funds as identified in accordance with section 3.975. The Web site must be updated at least annually.

62V.09 EXPIRATION AND SUNSET EXCLUSION.

Notwithstanding section 15.059, the board and its advisory committees shall not expire, except as specified in section 62V.04, subdivision 13. The board and its advisory committees are not subject to review or sunsetting under chapter 3D.

62V.10 RIGHT NOT TO PARTICIPATE.

Nothing in this chapter infringes on the right of a Minnesota citizen not to participate in MNsure.

62V.11 LEGISLATIVE OVERSIGHT COMMITTEE.

Subdivision 1.

Legislative oversight.

(a) The Legislative Oversight Committee is established to provide oversight to the implementation of this chapter and the operation of MNsure.

(b) The committee shall review the operations of MNsure at least annually and shall recommend necessary changes in policy, implementation, and statutes to the board and to the legislature.

(c) MNsure shall present to the committee the annual report required in section 62V.08, the appeals process under section 62V.05, subdivision 6, and the actions taken regarding the treatment of multiemployer plans.

Subd. 2.

Membership; meetings; compensation.

(a) The Legislative Oversight Committee shall consist of five members of the senate, three members appointed by the majority leader of the senate, and two members appointed by the minority leader of the senate; and five members of the house of representatives, three members appointed by the speaker of the house, and two members appointed by the minority leader of the house of representatives.

(b) Appointed legislative members serve at the pleasure of the appointing authority and shall continue to serve until their successors are appointed.

(c) The first meeting of the committee shall be convened by the chair of the Legislative Coordinating Commission. Members shall elect a chair at the first meeting. The chair must convene at least one meeting annually, and may convene other meetings as deemed necessary.

Subd. 4.

Review of costs.

The board shall submit for review the annual budget of MNsure for the next fiscal year by March 15 of each year, beginning March 15, 2014.

Subd. 5.

Review of Minnesota eligibility system funding and expenditures.

The committee shall review quarterly reports submitted by the Minnesota Eligibility System Executive Steering Committee under section 62V.055, subdivision 3, regarding Minnesota eligibility system funding and expenditures.

256L.01 DEFINITIONS.

Subd. 6.

MNsure.

"MNsure" means the state health benefit exchange as defined in section 62V.02.

Repealed Minnesota Rule: 18-5510

7700.0010 APPLICABILITY AND PURPOSE.

Subpart 1.

Applicability.

Parts 7700.0010 to 7700.0090 apply to an eligible entity that is an applicant to be certified to deliver consumer assistance services through MNsure.

Subp. 2.

Purpose.

Parts 7700.0010 to 7700.0090 establish the policies and procedures for certification as a consumer assistance partner through MNsure.

7700.0020 DEFINITIONS.

Subpart 1.

Scope.

As used in this chapter, the terms defined in this part have the meanings given them.

Subp. 2.

Affordable Care Act.

"Affordable Care Act" means the Patient Protection and Affordable Care Act of 2010, Public Law 111-148, as further defined through amendments to the act and regulations issued under the act.

Subp. 3.

Applicable staff.

"Applicable staff" means any person who has access authorized under this chapter to data stored in the MNsure Web tool.

Subp. 4.

Board.

"Board" means the Board of MNsure specified in Minnesota Statutes, section 62V.04.

Subp. 5.

Certified application counselor.

"Certified application counselor, " described in Code of Federal Regulations, title 45, part 155.225, means any entity certified by MNsure to provide consumer assistance services without any compensation from MNsure.

Subp. 6.

Conflict of interest.

"Conflict of interest" means any business, private, or personal interest sufficient to influence or appear to influence the objective execution of an entity's or individual's official or professional responsibilities to the extent necessary to carry out the functions of MNsure.

Subp. 7.

Consumer assistance partner.

"Consumer assistance partner " means entities certified by MNsure to serve as a navigator, in-person assister, or certified application counselor.

Subp. 8.

Cost-sharing reduction.

"Cost-sharing reduction" means reductions in cost sharing for an eligible individual enrolled in a silver level plan through MNsure or for an individual who is an American Indian or Alaska Native enrolled in a QHP through MNsure.

Subp. 9.

Enrollment.

"Enrollment" means enrolling individuals in a QHP or public health care program through MNsure, including properly utilizing the appropriate system tools, resources, and data to perform this function.

Subp. 10.

Individual tax credit.

"Individual tax credit" means premium tax credits specified in section 36B of the Internal Revenue Code, as added by section 1401 of the Affordable Care Act, which are provided on an advance basis to an eligible individual enrolled in a QHP through MNsure according to sections 1402 and 1412 of the Affordable Care Act.

Subp. 11.

In-person assister.

"In-person assister" means any entity certified by MNsure to provide services consistent with the applicable requirements of Code of Federal Regulations, title 45, part 155.205,(c), (d), and (e), and is distinct from a navigator.

Subp. 12.

Insurance producer.

"Insurance producer" has the meaning defined in Minnesota Statutes, section 60K.31.

Subp. 13.

MNsure.

"MNsure" means the "Minnesota Insurance Marketplace" under Minnesota Statutes, chapter 62V, created as a state health benefit exchange as described in section 1311 of the federal Patient Protection and Affordable Care Act, Public Law 111-148, and further defined through amendments to the act and regulations issued under the act.

Subp. 14.

Navigator.

"Navigator" means any entity certified by MNsure to serve as a navigator and has the meaning described in section 1311(i) of the federal Patient Protection and Affordable Care Act (ACA), Public Law 111-148, and further defined through amendments to the act and regulations issued under the act. For calendar year 2014, the navigator program shall be covered by Minnesota Statutes, section 256.962.

Subp. 15.

Qualified health plan or QHP.

"Qualified health plan" or "QHP" means a health plan that meets the definition in section 1301(a) of the Affordable Care Act, Public Law 111-148, and has been certified by the board according to Minnesota Statutes, section 62V.05, subdivision 5, to be offered through MNsure.

7700.0030 ELIGIBILITY REQUIREMENTS; CERTIFIED CONSUMER ASSISTANCE PARTNERS.

Subpart 1.

Federal prohibitions.

A.

Consumer assistance partners must not be health insurance issuers, subsidiaries of a health insurance issuer, stop loss insurance issuers, subsidiaries of a stop loss insurance issuer, or professional associations that include members of or lobby on behalf of the insurance industry according to federal requirements in Code of Federal Regulations, title 45, section 155.210 (d).

B.

Consumer assistance partners must not have a conflict of interest while serving as a consumer assistance partner.

(1)

Consumer assistance partners must not receive any compensation directly or indirectly from any health insurance issuer in connection with the enrollment of any individuals or employees in a qualified health plan or a nonqualified health plan as specified in Code of Federal Regulations, title 45, section 155.210 (d)(4).

(2)

Consumer assistance partners must follow the requirements pursuant to Minnesota's Level One Establishment Notice of Grant Award, Special Terms and Conditions, Attachment B, #19: "In order to provide services that meet the requirements of Code of Federal Regulations, title 45, sections 155.205 (d)-(e), and 155.405, individuals performing in-person assistance functions must operate in a fair and impartial manner and must meet and adhere to appropriate conflict of interest standards which include, but are not limited to the following: Do not receive any direct or indirect compensation from an issuer in connection with enrolling consumers in health plans; and are not subsidiaries of an issuer or associations that include members of, or lobby on behalf of, the insurance industry."

Subp. 2.

Qualifications.

A.

Consumer assistance partners must demonstrate the ability to carry out those responsibilities as defined by the board.

B.

Consumer assistance partners must:

(1)

demonstrate proven connections to the communities MNsure will serve, or demonstrate the ability to form relationships with consumers, including uninsured and underinsured consumers;

(2)

successfully complete MNsure's certification training program; and

(3)

comply with any privacy and security standards applicable to MNsure.

Subp. 3.

Eligible entities.

Consumer assistance partners eligible for certification by MNsure are any of the following entities able to demonstrate to the board that the entity has existing relationships, or could readily establish relationships with consumers in Minnesota, including uninsured, underinsured, and vulnerable populations, likely to be eligible to enroll through MNsure: 501(c)(3) community-based organizations, for-profit businesses, government agencies, and any other entity recognized by the Office of the Secretary of State including, but not limited to:

A.

community and consumer-focused nonprofit groups;

B.

trade, industry, and professional associations;

C.

farming organizations;

D.

religious organizations;

E.

chambers of commerce;

F.

insurance producers, subject to subpart 1;

G.

tribal organizations; and

H.

state or local human services agencies.

MNsure will consider coalitions or collaboratives of entities meeting the requirements of subpart 3.

7700.0040 RESPONSIBILITIES OF CONSUMER ASSISTANCE PARTNERS; CONSUMER ASSISTANCE SERVICES.

Subpart 1.

Duties and responsibilities.

As required in Code of Federal Regulations, title 45, section 155.210 (e), consumer assistance partners, at a minimum, must perform the following activities:

A.

maintain expertise in eligibility, enrollment, and program specifications and conduct public education activities;

B.

provide information and services in a fair, accurate, and impartial manner, and this information must acknowledge other health programs;

C.

facilitate enrollment in qualified health plans offered in MNsure;

D.

provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Service Act, or any other appropriate state agency or agencies for any enrollee with a grievance, complaint, or question regarding an enrollee's health plan, coverage, or a determination under such plan or coverage;

E.

provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by MNsure including individuals with limited English proficiency; and ensure accessibility and usability of tools and functions for individuals with disabilities according to the Americans with Disabilities Act and section 504 of the Rehabilitation Act; and

F.

comply with Title VI of the Civil Rights Act of 1964, section 1557 of the Americans with Disabilities Act, and other applicable federal law and regulation.

Subp. 2.

Consumer assistance services.

Consumer assistance partners and insurance producers certified by MNsure shall guide consumers through the application and enrollment process and facilitate access to the range of health coverage options available through MNsure by providing the following services, including but not limited to:

A.

informing consumers of health insurance options and the value of coverage, in addition to reviewing insurance options available through MNsure;

B.

informing individuals of application processes, required documentation, mandated requirements, and any exemption criteria;

C.

providing information and referrals to small employers on enrollment in the Small Business Health Options Program (SHOP) and any tax provisions, including credits and penalties, potentially affecting small employers;

D.

gauging eligibility through MNsure and providing referrals to appropriate support services or programs for further assistance, such as free health clinics;

E.

providing nonmedical referrals, to the extent possible, according to MNsure referral guidance;

F.

explaining program eligibility rules and providing application assistance for Medicaid/CHIP, premium tax credits, and cost-sharing reductions;

G.

assisting with the entry of information into enrollment tools and resources, including final submission of information;

H.

advising American Indians and Alaskan Natives on benefits specified by the Affordable Care Act, such as cost-sharing reductions, income exclusions, special open enrollment periods, and exemption from minimum health care coverage mandate;

I.

addressing questions regarding the submission of eligibility and enrollment verification documentation;

J.

facilitating referrals to insurance producers for individuals and families enrolling in qualified health plans through MNsure and requesting plan enrollment assistance beyond the scope of consumer assistance partners;

K.

facilitating referrals to community organizations, counties, or other appropriate nonprofit or public entities when individuals and families require technical expertise and assistance beyond the scope of the consumer assistance partner or insurance producer;

L.

explaining, discussing, and interpreting coverage and policies with consumers to facilitate plan selection; and

M.

assisting with plan comparison based upon individual priorities, including but not limited to metal tier levels, quality ranges, providers including, but not limited to, specialty care, pharmaceutical, dental and eye care, and total cost estimation including utilization and health status.

Regardless of services listed in this subpart, no consumer assistance partner may provide a service that requires licensure under Minnesota Statutes, chapter 60K, unless the consumer assistance partner has the appropriate licensure under Minnesota Statutes, chapter 60K.

7700.0050 CERTIFICATION TRAINING.

Subpart 1.

Consumer assistance partners.

MNsure shall develop a certification training program, administer Web-based training, and administer assessment of proficiency for navigators, in-person assisters, and certified application counselors. Training shall be made available to eligible entities by MNsure. MNsure may enter into agreements with third-party entities to deliver the MNsure certification training program curriculum. MNsure may audit any third-party entity program at any time and may terminate the training agreement at MNsure's discretion. Documentation of certification training completion shall be maintained by MNsure. To receive and maintain MNsure certification, all applicable staff of an entity serving as a navigator, in-person assister, or certified application counselor must complete the following required training modules with a minimum passing score, determined by MNsure, on all assigned training coursework. Modules include, but are not limited to, those specified in items A to E.

A.

MNsure Web tool that includes training on the use of the public Web site, online enrollment tools, and navigation of the navigator, in-person assister, or certified application counselor landing page.

B.

Affordable Care Act 101 that includes training on basic information on available public health care programs, referrals to other consumer assistance partners and insurance producers certified by MNsure, underserved and vulnerable populations, privacy and security as specified in part 7700.0080, and conflict of interest as specified in part 7700.0070.

C.

Public health care programs, premium tax credits, and cost-sharing reductions includes training on eligibility and enrollment rules and procedures, and means of appeal and dispute resolution.

D.

Qualified health plan includes training on eligibility and enrollment rules and procedures, the range of qualified health plan options offered through MNsure, and the means of appeal and dispute resolution.

E.

Overview of Minnesota licensure requirements to sell, solicit, or negotiate insurance.

Subp. 2.

Insurance producers.

MNsure shall establish minimum certification training standards for insurance producers certified to serve by MNsure. Training and assessment of proficiency for insurance producers shall be administered by MNsure. MNsure may enter into agreements with third-party entities to deliver the MNsure certification training program curriculum. MNsure may audit any third-party entity program at any time and may terminate the training agreement at MNsure's discretion. Training shall be made available to eligible insurance producers by MNsure. To receive and maintain MNsure certification, all applicable staff of an entity serving as a certified insurance producer must complete the required training modules in items A to E with a minimum passing score, determined by the board, on all assigned training coursework. Modules include, but are not limited to:

A.

MNsure Web tool that includes training on the use of the public Web site, online enrollment tools, and navigation of the insurance producer landing page;

B.

Affordable Care Act 101 that includes training on basic information on available public health care programs, referrals to consumer assistance partners serving MNsure, underserved and vulnerable populations, privacy and security as specified in part 7700.0080, and conflict of interest as specified in part 7700.0070;

C.

public health care programs, premium tax credits, and cost-sharing reductions includes training on eligibility and enrollment rules and procedures, and the means of appeal and dispute resolution;

D.

qualified health plans includes training on eligibility and enrollment rules and procedures, the range of qualified health plan options offered in MNsure, and the means of appeal and dispute resolution; and

E.

defined contributions includes training on federal requirements and MNsure online enrollment tools for small employers to provide a defined contribution towards a qualified health plan for their employees.

7700.0060 CERTIFICATION.

Subpart 1.

Consumer assistance partners.

Before providing any services, a navigator, in-person assister, or certified application counselor must be certified by MNsure by meeting the criteria in items A to F:

A.

enter into a formal agreement with MNsure by responding to MNsure's solicitation for navigators, in-person assisters, or certified application counselors;

B.

select, manage, and monitor individuals performing consumer assistance services and direct them to meet MNsure certification training standards by ensuring that all applicable staff participate in required MNsure sponsored training under part 7700.0050;

C.

comply with MNsure conflict of interest standards as specified in part 7700.0070;

D.

comply with MNsure privacy and security standards as specified in part 7700.0080;

E.

comply with MNsure account creation process; and

F.

comply with recertification requirements to be determined by MNsure.

Subp. 2.

Insurance producers.

Before providing any services through MNsure, an insurance producer must be certified by MNsure by meeting the criteria in items A to G:

A.

maintain active status as an insurance producer under part 7700.0020, subpart 12;

B.

inform MNsure of the intent to be certified by MNsure;

C.

ensure that all insurance producer and applicable staff and subcontractors participate in required MNsure certification training specified in part 7700.0050;

D.

disclose to MNsure which health carrier's qualified health plans offered through MNsure the insurance producer is authorized to sell;

E.

comply with MNsure privacy and security standards specified in part 7700.0080;

F.

comply with the MNsure account creation process; and

G.

comply with recertification requirements to be determined by MNsure.

Subp. 3.

Noncompliance.

At MNsure's discretion, certification may be withdrawn from a navigator, in-person assister, certified application counselor or individual for noncompliance with the certification requirements in subpart 1. At MNsure's discretion, certification may be withdrawn from an insurance producer entity or individual for noncompliance with the certification requirements in subpart 2.

Subp. 4.

Monitored performance.

At MNsure's discretion, a consumer assistance partner and MNsure certified insurance producer's performance may be monitored during the certification period. MNsure may require an underperforming entity to develop and implement a time-limited performance improvement plan. If performance is not to MNsure's satisfaction, certification to provide services through MNsure may be withdrawn.

7700.0070 CONFLICT OF INTEREST.

Subpart 1.

Framework; consumer assistance partners.

MNsure shall provide consumers with impartial, high-quality, community-based education and information, and in-person application and enrollment assistance through consumer assistance partners. In order to ensure the delivery of high quality services, to minimize or eliminate the existence of conflicts of interest and ensure integrity, MNsure will:

A.

screen for potential conflicts of interest during the consumer assistance partner selection process and throughout the term of engagement with these entities;

B.

require initial and ongoing training that includes instruction on providing impartial education and in-person assistance with consumer selection of a qualified health plan;

C.

require the consumer assistance partner to disclose all affiliations that may present a direct, indirect, or perceived conflict of interest which includes submission of a written attestation that the consumer assistance partner is not a health insurance issuer or issuer of stop loss insurance, a subsidiary of a health insurance issuer or issuer of stop loss insurance, or an association that includes members of, or lobbies on behalf of, the insurance industry;

D.

monitor the consumer assistance partner's performance and practice through reporting;

E.

monitor the consumer assistance partner through feedback tools on the MNsure Web site and through qualitative and quantitative evaluation tools;

F.

actively solicit customer satisfaction feedback on experience with MNsure; and

G.

as circumstances command, where a conflict of interest arises, require mitigation, revocation of certification, or termination of partnership with a consumer assistance partner.

Subp. 2.

Insurance producers.

All current conflict of interest requirements in Minnesota Rules and Minnesota Statutes shall apply to insurance producers.

7700.0080 PRIVACY AND SECURITY.

Pursuant to Code of Federal Regulations, title 45, part 155.260, MNsure shall require a navigator, in-person assister, certified application counselor, or insurance producer to annually attest that its data security and privacy practices are compliant with the applicable federal and state laws and supportive of MNsure data security and privacy practices. Any navigator, in-person assister, certified application counselor, or insurance producer must have specific authorization from MNsure prior to accessing data through MNsure according to Minnesota Statutes, section 62V.06, subdivision 8. The authorization must be immediately and permanently revoked under Minnesota Statutes, section 62V.06, subdivision 8, for any willful violation of Minnesota Statutes, chapter 13. MNsure has the right to inspect, assess, and audit a navigator, in-person assister, certified application counselor, or insurance producer's data security and privacy practices. Inadequate data security and privacy practices may result in termination of certification at the discretion of MNsure.

7700.0090 COMPENSATION.

Subpart 1.

Consumer assistance partners compensation.

Consumer assistance partner compensation may include, but is not limited to, per enrollment payments, grants, and pay-for-performance payments. The type of compensation is dependent on the specific role of the consumer assistance partner. The amount or rate of compensation is dependent on the specific role of the consumer assistance partner. The rate of per enrollment payments shall be set by the board on an annual basis. The initial payment rate and any subsequent changes to the payment rate must be published in the State Register. The payment rate is effective upon publication and applicable for all work completed on or after the payment rate effective date.

A.

Payment per enrollment.

(1)

Consumer assistance partners may receive payment for each successful enrollment through MNsure. The rate of payment shall be set by MNsure. The initial payment rate and any subsequent changes to the payment rate shall be published in the State Register. The payment rate is effective upon publication and applicable for all work completed on or after the payment rate effective date. Payments shall be paid based on the availability of funding.

(2)

Payments shall be made directly to the entity.

B.

Grants.

(1)

MNsure may award grants through a competitive process. The competitive process shall be based on solicitation, and at MNsure's discretion, grants shall be established based on the criteria outlined in the solicitation.

(2)

Disbursements of grant funding shall be paid per contract agreed to between the entity and MNsure.

C.

Pay-for-performance payments. At the discretion of MNsure, pay-for-performance payments shall be established to address specific performance measures including, but not limited to, targeted geographic areas, specific population barriers, disparities, or distinctive outreach activities.

Subp. 2.

Insurance producers.

Compensation for insurance producers is subject to Minnesota Statutes, section 62V.05, subdivision 3.

7700.0100 ADMINISTRATIVE REVIEW OF MNSURE ELIGIBILITY DETERMINATIONS.

Subpart 1.

Applicability.

Parts 7700.0100 to 7700.0105 govern the administration of MNsure eligibility appeals. Parts 7700.0100 to 7700.0105 must be read in conjunction with the federal Affordable Care Act, Public Law 111-148; Code of Federal Regulations, title 45, part 155; and Minnesota Statutes, chapter 62V; and sections 256.045 and 256.0451.

Subp. 2.

Applicability to medical assistance and MinnesotaCare.

Although MNsure offers a unique single marketplace for consumers to compare several health insurance coverage options, including coverage under medical assistance and MinnesotaCare, appeals rights and processes for medical assistance and MinnesotaCare are found in applicable federal or state statute or rule, including, but not limited to, parts 9505.0130, 9505.5105, 9505.0545, and 9506.0070, and Minnesota Statutes, sections 256.045, 256.0451, and 256L.10. Nothing in these rules should be construed to supersede, abridge, or in any way limit the appeal rights of appellants contesting issues covered or not covered under these rules that are available under applicable federal or state statute or rule, including, but not limited to, parts 9505.0130, 9505.5105, 9505.0545, and 9506.0070, and Minnesota Statutes, sections 256.045, 256.0451, and 256L.10. However, nothing in these rules prevent any MNsure consumer from filing appeals through MNsure.

Subp. 3.

Regulatory investigations.

Nothing in these rules limits or supersedes the ability of the commissioners of commerce and health to conduct investigations or facilitate appeals as authorized by laws administered by the Departments of Commerce and Health.

7700.0101 DEFINITIONS.

Subpart 1.

Scope.

As used in parts 7700.0100 to 7700.0105, the terms defined in this part have the meanings given them.

Subp. 2.

Agency.

"Agency" means the entity that made the eligibility determination being contested. Agency includes MNsure and, where applicable, any entity involved under a contract, subcontract, grant, or subgrant with MNsure that provides or operates programs or services for which appeals are available. Agency does not include the Minnesota Department of Commerce or the Minnesota Department of Health.

Subp. 3.

Appeal.

"Appeal" means a challenge to or dispute of an initial determination or redetermination made by MNsure enumerated under part 7700.0105, subpart 1, item A.

Subp. 4.

Appeal record.

"Appeal record" means all relevant records pertaining to the contested issues, including eligibility records filed in the proceeding, the appeal decision, all papers and requests filed in the proceeding, and if a hearing is held, the recording of the hearing testimony or an official report containing the substance of what happened at the hearing and any exhibits introduced at the hearing.

Subp. 5.

Appeals examiner.

"Appeals examiner" means a person appointed to conduct hearings under this part by the MNsure board and includes human services judges of the Department of Human Services and administrative law judges of the Office of Administrative Hearings, when acting under a delegation of authority from the MNsure board.

Subp. 6.

Appellant.

"Appellant" means the applicant or enrollee, the employer, or small business employer or employee submitting an appeal. Appellant includes the appellant's attorney or representative. An appellant who is not a business owner may file and appeal on his or her own behalf or on behalf of the appellant's household.

Subp. 7.

Business day.

"Business day" means any day other than a Saturday, Sunday, or legal holiday as defined in Minnesota Statutes, section 645.44.

Subp. 8.

Business hours.

"Business hours" means the hours between 8:30 a.m. and 4:30 p.m., Central Standard Time, on business days.

Subp. 8a.

Case file.

"Case file" means the information, documents, and data, in whatever form, which have been generated, collected, stored, or disseminated by the agency in connection with the person and the program or service involved.

Subp. 9.

Chief appeals examiner.

"Chief appeals examiner" means the chief human services judge of the Department of Human Services and the chief administrative law judge of the Office of Administrative Hearings, when acting under a delegation of authority from the MNsure board.

Subp. 10.

De novo review.

"De novo review" means a review of an appeal without deference to prior decisions in the case and can include making new findings of fact based on the appeal record.

Subp. 11.

Eligibility.

"Eligibility" means meeting the stipulated requirements for participation in a program or access to a service or product.

Subp. 12.

MNsure board or board.

"MNsure board" or "board" means the entity established in Minnesota Statutes, chapter 62V, as a board under Minnesota Statutes, section 15.012, and should be understood to include any individual or entity to whom the board has delegated a specific power or authority either directly or through an interagency agreement when that individual or entity is exercising the delegation.

Subp. 13.

Party or parties.

"Party" or "parties" means the appellants and agencies that are involved in an appeal and who have the legal right to make claims and defenses, offer proof, and examine and cross-examine witnesses during the appeal.

Subp. 14.

Person.

"Person" means a natural person.

Subp. 15.

Preponderance of the evidence.

"Preponderance of the evidence" means, in light of the record as a whole, the evidence leads the appeals examiner to believe that the finding of fact is more likely to be true than not true.

Subp. 16.

Representative.

"Representative" means a person who is empowered by the party to support, speak for, or act on behalf of the party. Representative includes legal counsel, relative, friend, or other spokesperson or authorized representative under Code of Federal Regulations, title 45, section 155.227.

Subp. 17.

Vacate.

"Vacate" means to set aside a previous action.

7700.0105 MNSURE ELIGIBILITY APPEALS.

Subpart 1.

Eligibility.

A.

MNsure appeals are available for the following actions:

(1)

initial determinations and redeterminations made by MNsure of individual eligibility to purchase a qualified health plan through MNsure, made in accordance with Code of Federal Regulations, title 45, sections 155.305, (a) and (b); 155.330; and 155.335;

(2)

initial determinations and redeterminations made by MNsure of eligibility for and level of advance payment of premium tax credit, and eligibility for and level of cost sharing reductions, made in accordance with Code of Federal Regulations, title 45, sections 155.305 (f) to (g); 155.330; and 155.335;

(3)

initial determinations and redeterminations made by MNsure of employer eligibility to purchase coverage for qualified employees through the Small Business Health Options Program under Code of Federal Regulations, title 45, section 155.710 (a);

(4)

initial determinations and redeterminations made by MNsure of employee eligibility to purchase coverage through the Small Business Health Options Program under Code of Federal Regulations, title 45, section 155.710 (e);

(5)

initial determinations and redeterminations made by MNsure of individual eligibility for an exemption from the individual responsibility requirement made in accordance with Code of Federal Regulations, title 45, section 155.605;

(6)

a failure by MNsure to provide timely notice of an eligibility determination in accordance with Code of Federal Regulations, title 45, sections 155.310 (g); 155.330 (e)(1)(ii); 155.335 (h)(ii); 155.610 (i); and 155.715 (e) and (f); and

(7)

in response to a notice from MNsure under Code of Federal Regulations, title 45, section 155.310 (h), a determination by MNsure that an employer does not provide minimum essential coverage through an employer-sponsored plan or that the employer does provide coverage but is not affordable coverage with respect to an employee.

B.

If an individual has been denied eligibility for medical assistance under Code of Federal Regulations, title 45, section 155.302 (b), an appeal of a determination of eligibility for advanced payments of the premium tax credit or cost-sharing reduction must also be treated as an appeal of medical assistance determination of eligibility.

Subp. 2.

Filing an appeal.

A.

To initiate an appeal, an appellant must file the appeal with MNsure as follows:

(1)

by mail;

(2)

by telephone;

(3)

by Internet; or

(4)

in person.

B.

MNsure must provide the necessary contact information for each method of filing an appeal with each written eligibility determination and also through the MNsure Web site.

C.

The agency must assist any potential appellant in filing an appeal when assistance is requested.

D.

An appeal must be received by MNsure within 90 days from the date of the notice of eligibility determination. There is a rebuttable presumption that the date of the notice of eligibility determination is five business days later than the date printed on the notice. The person may rebut this presumption by presenting evidence or testimony that they received the notice five business days after the date printed on the notice. An appeal received more than 90 days after the date of the eligibility notice will be dismissed. If the deadline for filing an appeal falls on a day that is not a business day, the filing deadline is the next business day.

E.

Appeal request forms will be available to persons through the Internet, by in-person request, by mail, and by telephone. The following information is requested, but not required, in an appeal:

(1)

name;

(2)

MNsure username;

(3)

date of birth;

(4)

address, including either an e-mail address, if available, or a mailing or physical address;

(5)

MNsure programs involved in the appeal, for which a list must be provided on the appeal request form;

(6)

reason for the appeal; and

(7)

in appeals of redeterminations of eligibility, whether the appellant intends to continue at the level of eligibility and benefits before the redetermination being appealed until the appeal decision.

F.

Appeals shall be accepted regardless of whether the requested information is provided on the form or the information is incomplete. However, failure by an appellant to provide all of the requested information may prevent resolution of the appeal or delivery of effective notice.

G.

The date of official receipt of appeals submitted after business hours, whether filed through the Internet or by telephone, is the next business day.

Subp. 3.

Notices and communications.

A.

The parties to an appeal have the right to the following timely notices and communications:

(1)

acknowledgement of receipt of the appeal and a scheduling order, including information regarding the appellant's eligibility pending appeal and an explanation that any advance payments of the premium tax credit paid on behalf of the tax filer pending appeal are subject to reconciliation; and

(2)

the decision and order of the MNsure board.

B.

Any notice sent to the appellant must also be sent to the appellant's attorney or representative.

C.

An appeals examiner shall not have ex parte contact on substantive issues with the agency, the appellant, or any person involved in an appeal. No agency employee shall review, interfere with, change, or attempt to influence the recommended decision of the appeals examiner in any appeal, except through the procedures allowed herein. The limitations in this subpart do not affect the board's authority to review or make final decisions.

Subp. 4.

Rescheduling.

A.

Requests to reschedule a hearing must be made in person, by telephone, through the Internet, or by mail to the appeals examiner. The rescheduling request may be made orally or in writing. The requesting party must provide the other party a copy of a written request or must otherwise notify the other party of the request if the request is made orally.

B.

Requests to reschedule a hearing with less than five calendar days' advance notice of the scheduled hearing date requires one attempt by the requesting party to contact the other party to notify them of the forthcoming request and to provide an opportunity to express disagreement, if any. Requests to reschedule a hearing with less than 24 hours' advance notice of the scheduled hearing date is at the discretion of the appeals examiner upon considering the potential prejudicial effect or burden to the appellant.

C.

Unless a determination is formally made in writing by the appeals examiner that a request to reschedule a hearing is made for the purpose of delay or where a party has expressed disagreement, as provided for in item B, and the reason for the disagreement outweighs the need for the rescheduling, a hearing must be rescheduled by the appeals examiner for good cause as determined by the appeals examiner. Good cause includes the following:

(1)

to accommodate a witness;

(2)

to obtain necessary evidence, preparation, or representation;

(3)

to review, evaluate, and respond to new evidence;

(4)

to permit negotiations of resolution between the parties;

(5)

to permit the agency to reconsider;

(6)

to permit actions not previously taken;

(7)

to accommodate a conflict of previously scheduled appointments;

(8)

to accommodate a physical or mental illness;

(9)

where an interpreter, translator, or other service necessary to accommodate a person with a disability is needed but not available; or

(10)

any other compelling reasons beyond the control of the party that prevents attendance at the originally scheduled time.

D.

If requested by the appeals examiner, a written statement confirming the reasons for the rescheduling request must be provided to the appeals examiner by the requesting party.

Subp. 4a.

Resolution offers.

The agency, in its discretion, may offer the appellant consideration to compromise or resolve the appeal. If such an offer is made, the appellant must communicate to MNsure the appellant's acceptance or denial, including plan enrollment selection, where applicable, within 14 calendar days from the day the offer is made or the offer expires.

Subp. 5.

Telephone, videoconference, or in-person hearing.

A.

A hearing may be conducted by telephone, videoconference, or in person. An in-person appeals hearing will only be held at the discretion of the appeals examiner, or if the person asserts that either the person or a witness has a physical or mental disability that would impair the person's ability to fully participate in a hearing held by interactive video technology. To have the hearing conducted by videoconference or in person, a person must make a specific request for that type of hearing.

B.

When an in-person hearing is granted, the appeals examiner shall conduct the hearing in the county where the person involved resides, unless an alternate location is mutually agreed upon before the hearing.

C.

Where federal law or regulation does not require a telephone, videoconference, or in-person hearing and allows for a review of documentary evidence through a desk review, a telephone, videoconference, or in-person hearing will only be provided when the appeals examiner determines that such a hearing would materially assist in resolving the issues presented by the appeal.

Subp. 6.

Emergency expedited appeals.

A.

An appellant has a right to an emergency expedited appeal when there is an immediate need for health services because a standard appeal could seriously jeopardize the appellant's life or health or ability to attain, maintain, or regain maximum function. An appellant must specify that an emergency expedited appeal is being requested when submitting the initial appeal. If an emergency develops during a pending appeal such that there has developed an immediate need for health services because a standard appeal could seriously jeopardize the appellant's life or health or ability to attain, maintain, or regain maximum function, an appellant may request an expedited appeal.

B.

An appeals examiner must grant an emergency expedited appeal if an appellant has any of the following conditions or circumstances:

(1)

pregnancy and postpartum care;

(2)

newborn baby;

(3)

prescriptions for chronic illnesses;

(4)

dialysis;

(5)

cancer treatment;

(6)

broken bones needing immediate treatment;

(7)

prescription refills necessitating physician visit;

(8)

outpatient treatment currently being received;

(9)

prescriptions for mental health conditions;

(10)

nonelective surgery;

(11)

heart disease;

(12)

severe mood and brain disorders (e.g., schizophrenia, bipolar disorder); or

(13)

other similar conditions or circumstances.

C.

If a request for an expedited appeal is denied, the appellant will be notified according to the process and time period required under the applicable federal law.

D.

If a request for an expedited appeal is accepted, the appeals examiner will issue a decision according to the process and time period required under the applicable federal law.

Subp. 7.

Interpreter and translation services.

A.

Appeals must be accessible to appellants who have limited English proficiency, appellants who require interpreter and translation services, and appellants with disabilities. An appeals examiner has a duty to inquire whether any person involved in the hearing needs the services of an interpreter, translator, or reasonable accommodations to accommodate a disability in order to participate in or to understand the appeal process.

B.

Necessary interpreter services, translation services, or reasonable accommodations must be provided at no cost to the person involved in the appeal.

C.

If an appellant requests interpreter services, translation services, or reasonable accommodations or it appears to the appeals examiner that necessary interpreter or translation services are needed but not available for the scheduled hearing, the hearing shall be rescheduled to the next available date when the appropriate services can be provided.

Subp. 8.

Access to data.

A.

Subject to the requirements of all applicable state and federal laws regarding privacy, confidentiality, and disclosure of personally identifiable information, the appellants and agencies involved in an appeals hearing must be allowed to access the appeal record upon request at a convenient place and time before and during the appeals hearing. Upon request, copies of the appeal record, including an electronic copy of the recorded hearing, must be provided at no cost and, upon request, must be mailed or sent by electronic transmission to the party or the party's representative.

B.

An appellant involved in an appeals hearing may enforce the right of access to data and copies of the case file by making a request to the appeals examiner. The appeals examiner shall make an appropriate order enforcing the appellant's right of access, including but not limited to ordering access to files, data, and documents possessed by the agency; continuing or rescheduling an appeal hearing to allow adequate time for access to data; or prohibiting use by the agency of files, data, or documents that have been generated, collected, stored, or disseminated in violation of the requirements of state or federal law, or when the documents have not been provided to the appellant involved in the appeal.

Subp. 9.

Data practices.

A.

Data on individuals, as defined in Minnesota Statutes, section 13.02, subdivision 5, will be collected about persons and appellants throughout the appeals process. The purpose of this data collection is to conduct an appeal. A party to an appeal is not required to supply data for an appeal. However, deciding which evidence and testimony to submit may have an impact on the outcome of the appeal decision. Certain other government officials may have access to information provided throughout the appeals process if this is allowed by law or pursuant to a valid court order.

B.

When an appeal proceeds beyond the MNsure appeals process to judicial review, the appeal record will be public unless the court with jurisdiction over the appeal issues a protective order. When the appeal proceeds outside of the MNsure appeals process to the United States Department of Health and Human Services, the record will be classified according to federal law governing the collection of data on individuals.

Subp. 10.

Appeal summary.

The agency must prepare an appeal summary for each appeal hearing. The appeal summary shall be delivered to each party and the MNsure appeals examiner at least three business days before the date of the appeal hearing. The appeals examiner shall confirm that the appeal summary is delivered to the party involved in the appeal as required under this subpart. Each party shall be provided, through the appeal summary or other reasonable methods, appropriate information about the procedures for the appeal hearing and an adequate opportunity to prepare. The contents of the appeal summary must be adequate to inform each party of the evidence on which the agency relies and the legal basis for the agency's action or determination.

Subp. 11.

Representation during appeal.

An appellant may personally appear in any appeal hearing and may be represented by an attorney or representative. A partnership may be represented by any of its members, an attorney, or other representative. A corporation or association may be represented by an officer, an attorney, or other representative. In a case involving an unrepresented appellant, the appeals examiner shall examine witnesses and receive exhibits for the purpose of identifying and developing in the appeal record relevant facts necessary for making an informed and fair decision. An unrepresented appellant shall be provided an adequate opportunity to respond to testimony or other evidence presented by the agency at the appeal hearing. The appeals examiner shall ensure that an unrepresented appellant has a full and reasonable opportunity at the appeal hearing to establish a record for appeal. An agency may be represented by an employee or an attorney, including an attorney employed by the agency as authorized by law.

Subp. 12.

Dismissals.

A.

The appeals examiner must dismiss an appeal if the appellant:

(1)

withdraws the appeal orally or in writing;

(2)

fails to appear at a scheduled appeal hearing or prehearing conference and good cause is not shown;

(3)

fails to submit a valid appeal; or

(4)

dies while the appeal is pending.

B.

If an appeal is dismissed, the appeals examiner must provide timely notice to the parties, which must include the reason for dismissal, an explanation of the dismissal's effect on the appellant's eligibility, and an explanation of how the appellant may show good cause why the dismissal should be vacated.

C.

The appeals examiner must vacate a dismissal if the appellant makes a written request within 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated. There is a rebuttable presumption that the date of the notice of dismissal is five business days later than the date printed on the notice. The person may rebut this presumption by presenting evidence or testimony that they received the notice later than five business days after the date printed on the notice. Good cause can be shown when there is:

(1)

a death or serious illness in the person's family;

(2)

a personal injury or physical or mental illness that reasonably prevents an appellant or witness from attending the hearing;

(3)

an emergency, crisis, including a mental health crisis, or unforeseen event that reasonably prevents an appellant or witness from attending the hearing;

(4)

an obligation or responsibility of an appellant or witness which a reasonable person, in the conduct of one's affairs, could reasonably determine takes precedence over attending the hearing;

(5)

lack of or failure to receive timely notice of the hearing in the preferred language of an appellant involved in the hearing;

(6)

excusable neglect, excusable inadvertence, or excusable mistake as determined by the appeals examiner; or

(7)

any other compelling reason beyond the control of the party as determined by the appeals examiner.

Subp. 13.

Prehearing conferences.

A.

The appeals examiner, at the examiner's discretion, prior to an appeal hearing may hold a prehearing conference to further the interests of justice or efficiency. The parties must participate in any prehearing conference held. A party may request a prehearing conference. The prehearing conference may be conducted by telephone, in writing, or in person. The prehearing conference may address the following issues:

(1)

disputes regarding access to files, evidence, subpoenas, or testimony;

(2)

the time required for the hearing or any need for expedited procedures or decision;

(3)

identification or clarification of legal or other issues that may arise at the hearing;

(4)

identification of and possible agreement to factual issues; and

(5)

scheduling and any other matter that will aid in the proper and fair functioning of the hearing.

B.

The appeals examiner shall make a record or otherwise contemporaneously summarize the prehearing conference in writing, which shall be sent to:

(1)

the parties; and

(2)

the party's attorney or representative.

Subp. 14.

Disqualification of appeals examiner.

A.

The chief appeals examiner shall remove an appeals examiner from any case where the appeals examiner believes that presiding over the case would create the appearance of unfairness or impropriety. No appeals examiner may hear any case where any of the parties to the appeal are related to the appeals examiner by blood or marriage. An appeals examiner must not hear any case if the appeals examiner has a financial or personal interest in the outcome. An appeals examiner having knowledge of such a relationship or interest must immediately notify the chief appeals examiner and be removed from the case.

B.

A party may move for the removal of an appeals examiner by written application of the party together with a statement of the basis for removal. Upon the motion of the party, the chief appeals examiner must decide whether the appeals examiner may hear the particular case. Removal of an appeals examiner under this item is at the discretion of the chief appeals examiner.

Subp. 15.

Status of eligibility and benefits pending appeal.

A.

In appeals involving a redetermination of an appellant's eligibility, the appellant shall continue at the level of eligibility and benefits before the redetermination being appealed only if the appellant affirmatively elects to receive them during the appeal.

B.

The appeal type, as specified in subpart 1, item A, determines what eligibility and benefits are available to be continued pending appeal. The availability of a continuation of eligibility and benefits is only available for appellants under subpart 1, item A, subitems (1) and (2). If appealing eligibility for advanced payments of premium tax credits and/or cost-sharing reductions, at issue is the amount of the advance payments of premium tax credits and/or cost-sharing reductions; and if appealing the eligibility to purchase a QHP through MNsure, at issue is the eligibility to purchase a QHP through MNsure.

C.

Where an appellant continues at the level of eligibility before the redetermination being appealed and the appeal decision upholds the redetermination being appealed, the appellant is subject to reconciliation and repayment of any overpayment.

Subp. 16.

Commencement and conduct of hearing.

A.

The appeals examiner shall begin each hearing by describing the process to be followed in the hearing, including the swearing in of witnesses, how testimony and evidence are presented, the order of examining and cross-examining witnesses, and the opportunity for an opening statement and a closing statement. The appeals examiner shall identify for the parties the issues to be addressed at the hearing and shall explain to the parties the burden of proof that applies to the appellant and the agency. The appeals examiner shall confirm, prior to proceeding with the hearing, that the appeal summary, if prepared, has been properly completed and provided to the parties, and that the parties have been provided documents and an opportunity to review the appeal record, as provided in this part.

B.

The appeals examiner shall act in a fair and impartial manner at all times. At the beginning of the appeal hearing, the agency must designate one person as a representative who shall be responsible for presenting the agency's evidence and questioning any witnesses. The appeals examiner shall make sure that both the agency and the appellant are provided sufficient time to present testimony and evidence, to confront and cross-examine all adverse witnesses, and to make any relevant statement at the hearing. All testimony in the hearing will be taken under oath or affirmation. The appeals examiner shall make reasonable efforts to explain the appeal hearing process to unrepresented appellants and shall ensure that the hearing is conducted fairly and efficiently. Upon the reasonable request of the appellant or the agency or at the discretion of the appeals examiner, the appeals examiner shall direct witnesses to remain outside the hearing room, except during individual testimony, when the appeals examiner determines that such action is appropriate to ensure a fair and impartial hearing. The appeals examiner shall not terminate the hearing before affording the appellant and the agency a complete opportunity to submit all admissible evidence and reasonable opportunity for oral or written statement. In the event that an appeal hearing extends beyond the time allotted, the appeal hearing shall be continued from day to day until completion. Appeal hearings that have been continued shall be timely scheduled to minimize delay in the disposition of the appeal.

C.

The appeal hearing shall be a de novo review and shall address the correctness and legality of the agency's action and shall not be limited simply to a review of the propriety of the agency's action. The appellant may raise and present evidence on all legal claims or defenses arising under state or federal law as a basis for the appeal, excluding any constitutional claims that are beyond the jurisdiction of the appeal hearing. The appeals examiner may take official notice of adjudicative facts.

D.

The burden of persuasion is governed by specific state or federal law and regulations that apply to the subject of the hearing. Unless otherwise required by specific state or federal laws that apply to the subject of the appeal, the appellant carries the burden to persuade the appeals examiner that a claim is true and must demonstrate such by a preponderance of the evidence.

E.

The appeals examiner shall accept all evidence, except evidence privileged by law, that is commonly accepted by reasonable people in the conduct of their affairs as having probative value on the issues to be addressed at the appeal hearing. The appeals examiner shall ensure for all cases that the appeal record is sufficiently complete to make a fair and accurate decision.

F.

The agency must present its evidence prior to or at the appeal hearing. The parties shall not be permitted to submit evidence after the hearing except:

(1)

by agreement at the hearing between the appellant, the agency, and the appeals examiner;

(2)

in response to new evidence; or

(3)

when determined necessary by the appeals examiner to receive evidence needed to sufficiently complete the appeal record and make a fair and accurate decision.

If a party submits evidence after the appeal hearing, the other party must be allowed sufficient opportunity to respond to the evidence.

Subp. 17.

Orders of the MNsure board.

A.

A timely, written decision must be issued in every appeal. Each decision must contain a clear ruling on the issues presented in the appeal hearing and contain a ruling only on questions directly presented by the appeal and the arguments raised in the appeal.

B.

A written decision must be issued within 90 days of the date the appeal is received, as administratively feasible, unless a shorter time is required by law.

C.

The decision must contain both findings of fact and conclusions of law, clearly separated and identified. The findings of fact must be based on the entire appeal record. Each finding of fact made by the appeals examiner shall be supported by a preponderance of the evidence unless a different standard is required by law. The legal claims or arguments of a participant do not constitute either a finding of fact or a conclusion of law, except to the extent the appeals examiner explicitly adopts an argument as a finding of fact or conclusion of law.

D.

The decision shall contain at least the following:

(1)

a listing of the date and place of the appeal hearing and the parties and persons appearing at the appeal hearing;

(2)

a clear and precise statement of the issues, including the dispute that is the subject of the appeal and the specific points that must be resolved in order to decide the case;

(3)

a listing of each of the materials constituting the appeal record that were placed into evidence at the appeal hearing, and upon which the appeal hearing decision is based;

(4)

the findings of fact based upon the entire appeal record. The findings of fact must be adequate to inform the parties and the public of the basis of the decision. If the evidence is in conflict on an issue that must be resolved, the findings of fact must state the reasoning used in resolving the conflict;

(5)

conclusions of law that address the legal authority for the appeal hearing and the ruling, and which give appropriate attention to the claims of the parties;

(6)

a clear and precise statement of the decision made resolving the dispute that is the subject of the appeal, including the effective date of the decision; and

(7)

written notice of any existing right to appeal, including taking an appeal to the United States Department of Health and Human Services and identifying the time frame for an appeal and that the decision is final unless appealed.

E.

The appeals examiner shall not independently investigate facts or otherwise rely on information not presented at the appeal hearing. However, if the appeals examiner needs further clarification from the parties, the appeals examiner may request clarification from the parties at any time until a decision is issued. The appeals examiner may not contact other agency personnel, except as provided in subpart 16. The appeals examiner's recommended decision must be based exclusively on the testimony and evidence made part of the appeals record, legal arguments presented, and the appeals examiner's research and knowledge of the law.

F.

The MNsure board shall review the recommended decision and accept or refuse to accept the decision. The MNsure board may accept the recommended order of an appeals examiner and issue the order to the parties or may refuse to accept the decision. Upon refusal, the MNsure board shall notify the parties of the refusal, state the reasons, and allow each party ten days to submit additional written argument on the matter. After the expiration of the ten-day period, the MNsure board shall issue an order on the matter to the parties. Refusal of the MNsure board to accept a decision must not delay the 90-day time limit to issue a decision.

G.

Orders of the MNsure board shall be implemented either:

(1)

prospectively on the first day of the month following the notice of appeal decision; or

(2)

retroactively to the date ordered by the appeals examiner, at the option of the appellant.

An appellant shall communicate to the agency the appellant's plan enrollment selection within 60 calendar days from the notice of the appeal decision or the enrollment opportunity expires.

Subp. 18.

Public access to hearings and decisions.

Appeal decisions must be maintained in a manner so that the public has ready access to previous decisions on particular topics, subject to appropriate procedures for compliance with applicable state and federal laws regarding the privacy, confidentiality, and disclosure, of personally identifiable information. Appeal hearings conducted under this part are not open to the public due to the not public classification of the information provided for inclusion in the appeal record.

Subp. 18a.

Reconsideration.

A.

A party aggrieved by an order of the MNsure board may appeal under subpart 19 or 20, as applicable, or request reconsideration by the MNsure board within 30 days after the date the MNsure board issues the order. The MNsure board may reconsider an order upon request of any party or on the MNsure board's own motion. A request for reconsideration does not stay implementation of the MNsure board's order. The party seeking reconsideration has the burden to demonstrate why the matter should be reconsidered. The request for reconsideration may include legal argument and proposed additional evidence supporting the request, but this information is not required. If proposed additional evidence is submitted, the party must explain why the proposed additional evidence was not provided at the time of the hearing. If reconsideration is granted, the other parties must be sent a copy of all material submitted in support of the request for reconsideration and must be given ten days to respond. Upon reconsideration, the MNsure board may issue an amended order or an order affirming the original order.

B.

Any order of the MNsure board issued under this subpart shall be final upon the parties unless an appeal is made in the manner provided under subpart 19 or 20, as applicable. Any order of the MNsure board is binding on the parties and must be implemented until the order is reversed.

C.

A vendor, contractor, health insurance carrier, or other MNsure stakeholder is not a party and may not request a hearing or seek judicial review of an order issued under this part unless the vendor, contractor, health insurance carrier, or other MNsure stakeholder is assisting an appellant as a representative.

Subp. 19.

Administrative review.

A.

Administrative review by the United States Department of Health and Human Services may be available for parties aggrieved by an order of the MNsure board.

B.

An appeal under this part must be filed with the United States Department of Health and Human Services and MNsure within 30 days of the date of the appeal decision according to the process required under the applicable federal regulations.

Subp. 20.

Judicial review.

An appellant may seek judicial review to the extent it is available under Minnesota Statutes, section 62V.05, subdivision 6, paragraphs (e) to (i), or as otherwise allowed by law.