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HF 3372

4th Engrossment - 85th Legislature (2007 - 2008) Posted on 12/15/2009 12:00am

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

Current Version - 4th Engrossment

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A bill for an act
relating to health; changing provisions for uniform billing forms and electronic
claim filing; establishing compliance procedures for electronic transactions;
amending Minnesota Statutes 2006, sections 62J.51, subdivisions 17, 18;
62J.52, subdivision 4; 62J.59; 72A.201, subdivision 4; Minnesota Statutes
2007 Supplement, sections 62J.52, subdivisions 1, 2; 62J.536, subdivision 1,
by adding subdivisions; repealing Minnesota Statutes 2006, sections 62J.52,
subdivision 5; 62J.58.

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

Section 1.

Minnesota Statutes 2006, section 62J.51, subdivision 17, is amended to read:


Subd. 17.

Uniform billing form CMS 1450.

"Uniform billing form CMS 1450"
means the new text beginmost current version of the new text enduniform billing form known as the CMS 1450 deleted text beginor
UB92,
deleted text end developed by the National Uniform Billing Committee deleted text beginin 1992 and approved for
implementation in October 1993, and any subsequent amendments to the form
deleted text end.

Sec. 2.

Minnesota Statutes 2006, section 62J.51, subdivision 18, is amended to read:


Subd. 18.

Uniform billing form CMS 1500.

"Uniform billing form CMS 1500"
means the deleted text begin1990deleted text end new text beginmost current new text endversion of the health insurance claim form, CMS 1500,
developed by the National Uniform Claim Committee deleted text beginand any subsequent amendments to
the form
deleted text end.

Sec. 3.

Minnesota Statutes 2007 Supplement, section 62J.52, subdivision 1, is amended
to read:


Subdivision 1.

Uniform billing form CMS 1450.

(a) On and after January 1,
1996, all institutional inpatient hospital services, ancillary services, institutionally owned
or operated outpatient services rendered by providers in Minnesota, and institutional
or noninstitutional home health services that are not being billed using an equivalent
electronic billing format, must be billed using the uniform billing form CMS 1450, except
as provided in subdivision 5.

(b) The instructions and definitions for the use of the uniform billing form CMS
1450 shall be in accordance with the uniform billing form manual specified by the
commissioner. In promulgating these instructions, the commissioner may utilize the
manual developed by the National Uniform Billing Committeedeleted text begin, as adopted and finalized
by the Minnesota Uniform Billing Committee
deleted text end.

(c) Services to be billed using the uniform billing form CMS 1450 include:
institutional inpatient hospital services and distinct units in the hospital such as psychiatric
unit services, physical therapy unit services, swing bed (SNF) services, inpatient state
psychiatric hospital services, inpatient skilled nursing facility services, home health
services (Medicare part A), and hospice services; ancillary services, where benefits are
exhausted or patient has no Medicare part A, from hospitals, state psychiatric hospitals,
skilled nursing facilities, new text beginICF/MR's,new text end and home health (Medicare part B); institutional
owned or operated outpatient services such as waivered services, hospital outpatient
services, including ambulatory surgical center services, hospital referred laboratory
services, hospital-based ambulance services, and other hospital outpatient services,
skilled nursing facilities, home health, freestanding renal dialysis centers, comprehensive
outpatient rehabilitation facilities (CORF), outpatient rehabilitation facilities (ORF), rural
health clinics,new text begin federally qualified health centers,new text end and community mental health centers;
home health services such as home health intravenous therapy providers, deleted text beginwaivered
services, personal care attendants,
deleted text end and hospice; and any other health care provider certified
by the Medicare program to use this form.

(d) On and after January 1, 1996, a mother and newborn child must be billed
separately, and must not be combined on one claim form.

(e) Services provided by Medicare Critical Access Hospitals electing Method
II billing will be allowed an exception to this provision to allow the inclusion of the
professional fees on the CMS 1450.

Sec. 4.

Minnesota Statutes 2007 Supplement, section 62J.52, subdivision 2, is amended
to read:


Subd. 2.

Uniform billing form CMS 1500.

(a) On and after January 1, 1996, all
noninstitutional health care services rendered by providers in Minnesota except dental
or pharmacy providers, that are not currently being billed using an equivalent electronic
billing format, must be billed using the health insurance claim form CMS 1500, except as
provided in subdivision 5.

(b) The instructions and definitions for the use of the uniform billing form CMS
1500 shall be in accordance with the manual developed by the Administrative Uniformity
Committee entitled standards for the use of the CMS 1500 form, dated February 1994,
as further defined by the commissioner.

(c) Services to be billed using the uniform billing form CMS 1500 include physician
services and supplies, durable medical equipment, noninstitutional ambulance services,
independent ancillary services including occupational therapy, physical therapy, speech
therapy and audiology, home infusion therapy, podiatry services, optometry services,
mental health licensed professional services, substance abuse licensed professional
services, nursing practitioner professional services, certified registered nurse anesthetists,
chiropractors, physician assistants, laboratories, medical suppliers, new text beginwaivered services,
personal care attendants,
new text endand other health care providers such as day activity centers and
freestanding ambulatory surgical centers.

(d) Services provided by Medicare Critical Access Hospitals electing Method
II billing will be allowed an exception to this provision to allow the inclusion of the
professional fees on the CMS 1450.

Sec. 5.

Minnesota Statutes 2006, section 62J.52, subdivision 4, is amended to read:


Subd. 4.

Uniform pharmacy billing form.

(a) On and after January 1, 1996,
all pharmacy services provided by pharmacists in Minnesota that are not currently
being billed using an equivalent electronic billing format shall be billed using the
NCPDP/universal claim formdeleted text begin, except as provided in subdivision 5deleted text end.

(b) The instructions and definitions for the use of the uniform claim form shall
be in accordance with instructions specified by the commissioner of healthdeleted text begin, except as
provided in subdivision 5
deleted text end.

Sec. 6.

Minnesota Statutes 2007 Supplement, section 62J.536, subdivision 1, is
amended to read:


Subdivision 1.

Electronic claims and eligibility transactions required.

(a)
Beginning January 15, 2009, all group purchasers must accept from health care providers
the eligibility for a health plan transaction described under Code of Federal Regulations,
title 45, part 162, subpart L. Beginning July 15, 2009, all group purchasers must accept
from health care providers the health care claims or equivalent encounter information
transaction described under Code of Federal Regulations, title 45, part 162, subpart K.

(b) Beginning January 15, 2009, all group purchasers must transmit to providers
the eligibility for a health plan transaction described under Code of Federal Regulations,
title 45, part 162, subpart L. Beginning December deleted text begin1deleted text endnew text begin 15new text end, 2009, all group purchasers must
transmit to providers the health care payment and remittance advice transaction described
under Code of Federal Regulations, title 45, part 162, subpart P.

(c) Beginning January 15, 2009, all health care providers must submit to group
purchasers the eligibility for a health plan transaction described under Code of Federal
Regulations, title 45, part 162, subpart L. Beginning July 15, 2009, all health care
providers must submit to group purchasers the health care claims or equivalent encounter
information transaction described under Code of Federal Regulations, title 45, part 162,
subpart K.

(d) Beginning January 15, 2009, all health care providers must accept from group
purchasers the eligibility for a health plan transaction described under Code of Federal
Regulations, title 45, part 162, subpart L. Beginning December 15, 2009, all health care
providers must accept from group purchasers the health care payment and remittance
advice transaction described under Code of Federal Regulations, title 45, part 162, subpart
P.

(e) Each of the transactions described in paragraphs (a) to (d) shall require the use
of a single, uniform companion guide to the implementation guides described under
Code of Federal Regulations, title 45, part 162. The companion guides will be developed
pursuant to subdivision 2.

(f) Notwithstanding any other provisions in sections 62J.50 to 62J.61, all group
purchasers and health care providers must exchange claims and eligibility information
electronically using the transactions, companion guides, implementation guides, and
timelines required under this subdivision. Group purchasers may not impose any fee on
providers for the use of the transactions prescribed in this subdivision.

(g) Nothing in this subdivision shall prohibit group purchasers and health care
providers from using a direct data entry, Web-based methodology for complying with
the requirements of this subdivision. Any direct data entry method for conducting
the transactions specified in this subdivision must be consistent with the data content
component of the single, uniform companion guides required in paragraph (e) and the
implementation guides described under Code of Federal Regulations, title 45, part 162.

Sec. 7.

Minnesota Statutes 2007 Supplement, section 62J.536, is amended by adding a
subdivision to read:


new text begin Subd. 4. new text end

new text begin Group purchasers not covered by HIPAA. new text end

new text begin (a) For transactions with
group purchasers defined in section 62J.03, subdivision 6, that are not covered under
United States Code, title 42, sections 1320d to 1320d-8, the requirements of this section
are modified as follows:
new text end

new text begin (1) The group purchasers may be exempt from one or more of the requirements
to exchange claims and eligibility information electronically using the transactions,
companion guides, implementation guides, and timelines in subdivision 1 if the
commissioner of health determines that:
new text end

new text begin (i) a transaction is incapable of exchanging data that are currently being exchanged
on paper and is necessary to accomplish the purpose of the transaction; or
new text end

new text begin (ii) another national electronic transaction standard would be more appropriate and
effective to accomplish the purpose of the transaction.
new text end

new text begin (2) If group purchasers are exempt from one or more of the requirements to exchange
claims and eligibility information electronically using the transactions, companion guides,
implementation guides, and timelines in subdivision 1, providers shall also be exempt
from exchanging those transactions with the group purchaser.
new text end

new text begin (3) If the commissioner of health exempts a group purchaser from one or more of
the requirements because a transaction is incapable of exchanging data that are currently
being exchanged on paper and are necessary to accomplish the purpose of the transaction,
the commissioner shall review that exemption annually. If the commissioner determines
that the exemption is no longer necessary or appropriate, the commissioner of health shall
adopt rules pursuant to section 62J.61 establishing and requiring group purchasers and
health care providers to use the transactions and the uniform, standard companion guides
required under subdivision 1, paragraph (e). Group purchasers and providers shall have 12
months to implement any rules adopted.
new text end

new text begin (4) If the commissioner of health exempts a group purchaser from one or more of
the requirements because another national electronic transaction standard would be more
appropriate and effective to accomplish the purpose of the transaction, the commissioner
shall adopt rules pursuant to section 62J.61 establishing and requiring group purchasers
and health care providers to use the national electronic transaction standard. Group
purchasers and providers shall have 12 months to implement any rules adopted.
new text end

new text begin (5) The requirement of paper claims attachments shall not indicate that a health
care claims or equivalent encounter information transaction described under Code of
Federal Regulations, title 45, part 162, subpart K, is incapable of exchanging data that
are currently being exchanged on paper provided that the electronic health care claims
transaction has a mechanism to link the paper attachments to the electronic claim.
new text end

Sec. 8.

Minnesota Statutes 2007 Supplement, section 62J.536, is amended by adding a
subdivision to read:


new text begin Subd. 5. new text end

new text begin Compliance and investigations. new text end

new text begin (a) The commissioner of health shall, to
the extent practicable, seek the cooperation of health care providers and group purchasers
in obtaining compliance with this section and may provide technical assistance to health
care providers and group purchasers.
new text end

new text begin (b) A person who believes a health care provider or group purchaser is not complying
with the requirements of this section may file a complaint with the commissioner of health.
Complaints filed under this section must meet the following requirements:
new text end

new text begin (1) A complaint must be filed in writing, either on paper or electronically.
new text end

new text begin (2) A complaint must name the person that is the subject of the complaint and
describe the acts or omissions believed to be in violation of this section.
new text end

new text begin (3) A complaint must be filed within 180 days of when the complainant knew or
should have known that the act or omission complained of occurred.
new text end

new text begin (4) The commissioner may prescribe additional procedures for the filing of
complaints as required to satisfy the requirements of this section.
new text end

new text begin (c) The commissioner of health may investigate complaints filed under this section.
The investigation may include a review of the pertinent policies, procedures, or practices
of the health care provider or group purchaser and of the circumstances regarding any
alleged violation. At the time of initial written communication with the health care
provider or group purchaser about the complaint, the commissioner of health shall
describe the acts or omissions that are the basis of the complaint. The commissioner
may conduct compliance reviews to determine whether health care providers and group
purchasers are complying with this section.
new text end

new text begin (d) Health care providers and group purchasers must cooperate with the
commissioner of health if the commissioner undertakes an investigation or compliance
review of the policies, procedures, or practices of the health care provider or group
purchaser to determine compliance with this section. This cooperation includes, but is
not limited to:
new text end

new text begin (1) A health care provider or group purchaser must permit access by the
commissioner of health during normal business hours to its facilities, books, records,
accounts, and other sources of information that are pertinent to ascertaining compliance
with this section.
new text end

new text begin (2) If any information required of a health care provider or group purchaser under
this section is in the exclusive possession of any other agency, institution, or person and
the other agency, institution, or person fails or refuses to furnish the information, the
health care provider or group purchaser must so certify and set forth what efforts it has
made to obtain the information.
new text end

new text begin (3) Any individually identifiable health information obtained by the commissioner
of health in connection with an investigation or compliance review under this section
may not be used or disclosed by the commissioner of health, except as necessary for
ascertaining or enforcing compliance with this section.
new text end

new text begin (e) If an investigation of a complaint indicates noncompliance, the commissioner
of health shall attempt to reach a resolution of the matter by informal means. Informal
means may include demonstrated compliance or a completed corrective action plan or
other agreement. If the matter is resolved by informal means, the commissioner of health
shall so inform the health care provider or group purchaser and, if the matter arose from a
complaint, the complainant, in writing. If the matter is not resolved by informal means,
the commissioner of health shall:
new text end

new text begin (1) inform the health care provider or group purchaser and provide an opportunity
for the health care provider or group purchaser to submit written evidence of any
mitigating factors or other considerations. The health care provider or group purchaser
must submit any such evidence to the commissioner of health within 30 calendar days
of receipt of the notification; and
new text end

new text begin (2) inform the health care provider or group purchaser, through a notice of proposed
determination according to paragraph (i), that the commissioner of health finds that a
civil money penalty should be imposed.
new text end

new text begin (f) If, after an investigation or a compliance review, the commissioner of health
determines that further action is not warranted, the commissioner of health shall so inform
the health care provider or group purchaser and, if the matter arose from a complaint, the
complainant, in writing.
new text end

new text begin (g) A health care provider or group purchaser may not threaten, intimidate, coerce,
harass, discriminate against, or take any other retaliatory action against any individual
or other person for:
new text end

new text begin (1) filing of a complaint under this section;
new text end

new text begin (2) testifying, assisting, or participating in an investigation, compliance review,
proceeding, or contested case proceeding under this section; or
new text end

new text begin (3) opposing any act or practice made unlawful by this section, provided the
individual or person has a good faith belief that the practice opposed is unlawful, and
the manner of opposition is reasonable and does not involve an unauthorized disclosure
of a patient's health information.
new text end

new text begin (h) The commissioner of health may impose a civil money penalty on a health care
provider or group purchaser if the commissioner of health determines that the health
care provider or group purchaser has violated this section. If the commissioner of health
determines that more than one health care provider or group purchaser was responsible
for a violation, the commissioner of health may impose a civil money penalty against
each health care provider or group purchaser. The amount of a civil money penalty shall
be determined as follows:
new text end

new text begin (1) The amount of a civil money penalty shall be up to $100 for each violation, but
not exceed $25,000 for identical violations during a calendar year.
new text end

new text begin (2) In the case of continuing violation of this section, a separate violation occurs each
business day that the health care provider or group purchaser is in violation of this section.
new text end

new text begin (3) In determining the amount of any civil money penalty, the commissioner of health
may consider as aggravating or mitigating factors, as appropriate, any of the following:
new text end

new text begin (i) the nature of the violation, in light of the purpose of the goals of this section;
new text end

new text begin (ii) the time period during which the violation occurred;
new text end

new text begin (iii) whether the violation hindered or facilitated an individual's ability to obtain
health care;
new text end

new text begin (iv) whether the violation resulted in financial harm;
new text end

new text begin (v) whether the violation was intentional;
new text end

new text begin (vi) whether the violation was beyond the direct control of the health care provider
or group purchaser;
new text end

new text begin (vii) any history of prior compliance with the provisions of this section, including
violations;
new text end

new text begin (viii) whether and to what extent the provider or group purchaser has attempted to
correct previous violations;
new text end

new text begin (ix) how the health care provider or group purchaser has responded to technical
assistance from the commissioner of health provided in the context of a compliance
effort; or
new text end

new text begin (x) the financial condition of the health care provider or group purchaser including,
but not limited to, whether the healthcare provider or group purchaser had financial
difficulties that affected its ability to comply or whether the imposition of a civil money
penalty would jeopardize the ability of the health care provider or group purchaser to
continue to provide, or to pay for, health care.
new text end

new text begin (i) If a penalty is proposed according to this section, the commissioner of health
must deliver, or send by certified mail with return receipt requested, to the respondent
written notice of the commissioner of health's intent to impose a penalty. This notice
of proposed determination must include:
new text end

new text begin (1) a reference to the statutory basis for the penalty;
new text end

new text begin (2) a description of the findings of fact regarding the violations with respect to
which the penalty is proposed;
new text end

new text begin (3) the amount of the proposed penalty;
new text end

new text begin (4) any circumstances described in paragraph (i) that were considered in determining
the amount of the proposed penalty;
new text end

new text begin (5) instructions for responding to the notice, including a statement of the respondent's
right to a contested case proceeding and a statement that failure to request a contested case
proceeding within 30 calendar days permits the imposition of the proposed penalty; and
new text end

new text begin (6) the address to which the contested case proceeding request must be sent.
new text end

new text begin (j) A health care provider or group purchaser may contest whether the finding of
facts constitute a violation of this section, according to a contested case proceeding as set
forth in sections 14.57 to 14.62, subject to appeal according to sections 14.63 to 14.68.
new text end

new text begin (k) Any data collected by the commissioner of health as part of an active
investigation or active compliance review under this section are classified as protected
nonpublic data pursuant to section 13.02, subdivision 13, in the case of data not on
individuals and confidential pursuant to section 13.02, subdivision 3, in the case of data
on individuals. Data describing the final disposition of an investigation or compliance
review are classified as public.
new text end

new text begin (l) Civil money penalties imposed and collected under this subdivision shall be
deposited into a revolving fund and are appropriated to the commissioner of health for the
purposes of this subdivision, including the provision of technical assistance.
new text end

Sec. 9.

Minnesota Statutes 2006, section 62J.59, is amended to read:


62J.59 IMPLEMENTATION OF NCPDP TELECOMMUNICATIONS
STANDARD FOR PHARMACY CLAIMS.

(a) deleted text beginBeginning January 1, 1996,deleted text end All category I and II deleted text beginpharmacistsdeleted text end new text beginpharmacies new text endlicensed
in this state shall deleted text beginacceptdeleted text end new text beginuse new text endthe new text beginmost recent HIPAA-mandated version of the new text endNCPDP
telecommunication standard deleted text beginformat 3.2deleted text end or the NCPDP deleted text begintape billing and payment format 2.0deleted text end
new text begin batch standard new text endfor the electronic submission of claims new text beginto group purchasers new text endas appropriate.

(b) deleted text beginBeginning January 1, 1996,deleted text end All category I and category II group purchasers
in this state shall use the new text beginmost recent HIPAA-mandated version of the new text endNCPDP
telecommunication standard deleted text beginformat 3.2deleted text end or NCPDP deleted text begintape billing and payment format 2.0deleted text end
new text begin batch standard new text endfor new text beginthe new text endelectronic deleted text beginsubmission of payment informationdeleted text end new text beginNCPDP response
transaction
new text endto deleted text beginpharmacistsdeleted text endnew text begin pharmacies as appropriatenew text end.

Sec. 10.

Minnesota Statutes 2006, section 72A.201, subdivision 4, is amended to read:


Subd. 4.

Standards for claim filing and handling.

The following acts by an
insurer, an adjuster, a self-insured, or a self-insurance administrator constitute unfair
settlement practices:

(1) except for claims made under a health insurance policy, after receiving
notification of claim from an insured or a claimant, failing to acknowledge receipt of the
notification of the claim within ten business days, and failing to promptly provide all
necessary claim forms and instructions to process the claim, unless the claim is settled
within ten business days. The acknowledgment must include the telephone number of the
company representative who can assist the insured or the claimant in providing information
and assistance that is reasonable so that the insured or claimant can comply with the policy
conditions and the insurer's reasonable requirements. If an acknowledgment is made by
means other than writing, an appropriate notation of the acknowledgment must be made in
the claim file of the insurer and dated. An appropriate notation must include at least the
following information where the acknowledgment is by telephone or oral contact:

(i) the telephone number called, if any;

(ii) the name of the person making the telephone call or oral contact;

(iii) the name of the person who actually received the telephone call or oral contact;

(iv) the time of the telephone call or oral contact; and

(v) the date of the telephone call or oral contact;

(2) failing to reply, within ten business days of receipt, to all other communications
about a claim from an insured or a claimant that reasonably indicate a response is
requested or needed;

(3)(i) unless provided otherwise by clause (ii) or (iii), other law, or in the policy,
failing to complete its investigation and inform the insured or claimant of acceptance or
denial of a claim within 30 business days after receipt of notification of claim unless
the investigation cannot be reasonably completed within that time. In the event that the
investigation cannot reasonably be completed within that time, the insurer shall notify
the insured or claimant within the time period of the reasons why the investigation is not
complete and the expected date the investigation will be complete. For claims made under
a health policy the notification of claim must be in writing;

(ii) for claims submitted under a health policy, the insurer must comply with all of
the requirements of section 62Q.75;

(iii) for claims submitted under a health policy that are accepted, the insurer must
notify the insured or claimant no less than semiannually of the disposition of claims of the
insured or claimant. new text beginNotwithstanding the requirements of section 72A.20, subdivision
37, this notification requirement is satisfied if the information related to the acceptance of
the claim is made accessible to the insured or claimant on a secured Web site maintained
by the insurer.
new text endFor purposes of this clause, acceptance of a claim means that there is no
additional financial liability for the insured or claimant, either because there is a flat
co-payment amount specified in the health plan or because there is no co-payment,
deductible, or coinsurance owed;

(4) where evidence of suspected fraud is present, the requirement to disclose their
reasons for failure to complete the investigation within the time period set forth in clause
(3) need not be specific. The insurer must make this evidence available to the Department
of Commerce if requested;

(5) failing to notify an insured who has made a notification of claim of all available
benefits or coverages which the insured may be eligible to receive under the terms of a
policy and of the documentation which the insured must supply in order to ascertain
eligibility;

(6) unless otherwise provided by law or in the policy, requiring an insured to give
written notice of loss or proof of loss within a specified time, and thereafter seeking to
relieve the insurer of its obligations if the time limit is not complied with, unless the
failure to comply with the time limit prejudices the insurer's rights and then only if the
insurer gave prior notice to the insured of the potential prejudice;

(7) advising an insured or a claimant not to obtain the services of an attorney or
an adjuster, or representing that payment will be delayed if an attorney or an adjuster
is retained by the insured or the claimant;

(8) failing to advise in writing an insured or claimant who has filed a notification of
claim known to be unresolved, and who has not retained an attorney, of the expiration of
a statute of limitations at least 60 days prior to that expiration. For the purposes of this
clause, any claim on which the insurer has received no communication from the insured
or claimant for a period of two years preceding the expiration of the applicable statute
of limitations shall not be considered to be known to be unresolved and notice need not
be sent pursuant to this clause;

(9) demanding information which would not affect the settlement of the claim;

(10) unless expressly permitted by law or the policy, refusing to settle a claim of an
insured on the basis that the responsibility should be assumed by others;

(11) failing, within 60 business days after receipt of a properly executed proof of loss,
to advise the insured of the acceptance or denial of the claim by the insurer. No insurer
shall deny a claim on the grounds of a specific policy provision, condition, or exclusion
unless reference to the provision, condition, or exclusion is included in the denial. The
denial must be given to the insured in writing with a copy filed in the claim file;

(12) denying or reducing a claim on the basis of an application which was altered or
falsified by the agent or insurer without the knowledge of the insured;

(13) failing to notify the insured of the existence of the additional living expense
coverage when an insured under a homeowners policy sustains a loss by reason of a
covered occurrence and the damage to the dwelling is such that it is not habitable;

(14) failing to inform an insured or a claimant that the insurer will pay for an
estimate of repair if the insurer requested the estimate and the insured or claimant had
previously submitted two estimates of repair.

Sec. 11. new text begin REPEALER.
new text end

new text begin Minnesota Statutes 2006, sections 62J.52, subdivision 5; and 62J.58, new text end new text begin are repealed.
new text end