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Minnesota Legislature

Office of the Revisor of Statutes

HF 779

1st Unofficial Engrossment - 88th Legislature (2013 - 2014) Posted on 05/07/2013 05:48pm

KEY: stricken = removed, old language.
underscored = added, new language.
1.1A bill for an act
1.2relating to health plan regulation; regulating policy and contract coverages;
1.3conforming state law to federal requirements; establishing health plan market
1.4rules; modifying the designation of essential community providers;amending
1.5Minnesota Statutes 2012, sections 43A.23, subdivision 1; 43A.317, subdivision
1.66; 60A.08, subdivision 15; 62A.011, subdivision 3, by adding subdivisions;
1.762A.02, by adding a subdivision; 62A.03, subdivision 1; 62A.04, subdivision 2;
1.862A.047; 62A.049; 62A.136; 62A.149, subdivision 1; 62A.17, subdivisions 2,
1.96; 62A.21, subdivision 2b; 62A.28, subdivision 2; 62A.302; 62A.615; 62A.65,
1.10subdivisions 3, 5, 6, 7, by adding subdivisions; 62C.14, subdivision 5; 62C.142,
1.11subdivision 2; 62D.07, subdivision 3; 62D.095; 62D.124, subdivision 4; 62D.181,
1.12subdivision 7; 62E.02, by adding a subdivision; 62E.04, subdivision 4, by adding
1.13a subdivision; 62E.06, subdivision 1; 62E.09; 62E.10, subdivision 7; 62H.04;
1.1462L.02, subdivisions 11, 14a, 26, by adding a subdivision; 62L.03, subdivisions
1.151, 3, 4, 6; 62L.045, subdivisions 2, 4; 62L.05, subdivision 10; 62L.06; 62L.08;
1.1662L.12, subdivision 2; 62M.05, subdivision 3a; 62M.06, subdivision 1; 62Q.01,
1.17by adding subdivisions; 62Q.021; 62Q.17, subdivision 6; 62Q.18, by adding a
1.18subdivision; 62Q.19, subdivision 1; 62Q.23; 62Q.43, subdivision 2; 62Q.47;
1.1962Q.52; 62Q.55; 62Q.68, subdivision 1; 62Q.69, subdivision 3; 62Q.70,
1.20subdivisions 1, 2; 62Q.71; 62Q.73; 62Q.75, subdivision 1; 62Q.80, subdivision
1.212; 72A.20, subdivision 35; 471.61, subdivision 1a; proposing coding for new law
1.22in Minnesota Statutes, chapters 62A; 62Q; proposing coding for new law as
1.23Minnesota Statutes, chapter 62K; repealing Minnesota Statutes 2012, sections
1.2462A.615; 62A.65, subdivision 6; 62E.02, subdivision 7; 62E.16; 62E.20; 62L.02,
1.25subdivisions 4, 18, 19, 23, 24; 62L.05, subdivisions 1, 2, 3, 4, 4a, 5, 6, 7, 11, 12,
1.2613; 62L.081; 62L.10, subdivision 5; 62Q.37, subdivision 5.
1.27BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

1.28ARTICLE 1
1.29CONFORMING STATE LAW TO AFFORDABLE CARE ACT

1.30    Section 1. Minnesota Statutes 2012, section 43A.23, subdivision 1, is amended to read:
1.31    Subdivision 1. General. (a) The commissioner is authorized to request proposals
1.32or to negotiate and to enter into contracts with parties which in the judgment of the
2.1commissioner are best qualified to provide service to the benefit plans. Contracts entered
2.2into are not subject to the requirements of sections 16C.16 to 16C.19. The commissioner
2.3may negotiate premium rates and coverage. The commissioner shall consider the cost of
2.4the plans, conversion options relating to the contracts, service capabilities, character,
2.5financial position, and reputation of the carriers, and any other factors which the
2.6commissioner deems appropriate. Each benefit contract must be for a uniform term of at
2.7least one year, but may be made automatically renewable from term to term in the absence
2.8of notice of termination by either party. A carrier licensed under chapter 62A is exempt
2.9from the taxes imposed by chapter 297I on premiums paid to it by the state.
2.10    (b) All self-insured hospital and medical service products must comply with coverage
2.11mandates, data reporting, and consumer protection requirements applicable to the licensed
2.12carrier administering the product, had the product been insured, including chapters 62J,
2.1362M, and 62Q. Any self-insured products that limit coverage to a network of providers
2.14or provide different levels of coverage between network and nonnetwork providers shall
2.15comply with section 62D.123 and geographic access standards for health maintenance
2.16organizations adopted by the commissioner of health in rule under chapter 62D.
2.17    (c) Notwithstanding paragraph (b), a self-insured hospital and medical product
2.18offered under sections 43A.22 to 43A.30 is not required to extend dependent coverage
2.19to an eligible employee's unmarried child under the age of 25 to the full extent required
2.20under chapters 62A and 62L. Dependent child coverage must, at a minimum, extend to an
2.21eligible employee's unmarried dependent child who is under the age of 19 or an unmarried
2.22child under the age of 25 who is a full-time student. A person who is at least 19 years of
2.23age but who is under the age of 25 and who is not a full-time student must be permitted
2.24to be enrolled as a dependent of an eligible employee until age 25 if the person: to the
2.25limiting age as defined in section 62Q.01, subdivision 9, disabled children to the extent
2.26required in sections 62A.14 and 62A.141, and dependent grandchildren to the extent
2.27required in sections 62A.042 and 62A.302.
2.28(1) was a full-time student immediately prior to being ordered into active military
2.29service, as defined in section 190.05, subdivision 5b or 5c;
2.30(2) has been separated or discharged from active military service; and
2.31(3) would be eligible to enroll as a dependent of an eligible employee, except that
2.32the person is not a full-time student.
2.33The definition of "full-time student" for purposes of this paragraph includes any student
2.34who by reason of illness, injury, or physical or mental disability as documented by
2.35a physician is unable to carry what the educational institution considers a full-time
2.36course load so long as the student's course load is at least 60 percent of what otherwise
3.1is considered by the institution to be a full-time course load. Any notice regarding
3.2termination of coverage due to attainment of the limiting age must include information
3.3about this definition of "full-time student."
3.4    (d) Beginning January 1, 2010, the health insurance benefit plans offered in the
3.5commissioner's plan under section 43A.18, subdivision 2, and the managerial plan under
3.6section 43A.18, subdivision 3, must include an option for a health plan that is compatible
3.7with the definition of a high-deductible health plan in section 223 of the United States
3.8Internal Revenue Code.
3.9EFFECTIVE DATE.This section is effective the day following final enactment.

3.10    Sec. 2. Minnesota Statutes 2012, section 43A.317, subdivision 6, is amended to read:
3.11    Subd. 6. Individual eligibility. (a) Procedures. The commissioner shall establish
3.12procedures for eligible employees and other eligible individuals to apply for coverage
3.13through the program.
3.14(b) Employees. An employer shall determine when it applies to the program the
3.15criteria its employees must meet to be eligible for coverage under its plan. An employer
3.16may subsequently change the criteria annually or at other times with approval of the
3.17commissioner. The criteria must provide that new employees become eligible for coverage
3.18after a probationary period of at least 30 days, but no more than 90 days.
3.19(c) Other individuals. An employer may elect to cover under its plan:
3.20(1) the spouse, dependent children to the limiting age as defined in section 62Q.01,
3.21subdivision 9, disabled children to the extent required in sections 62A.14 and 62A.141,
3.22and dependent grandchildren of a covered employee to the extent required in sections
3.2362A.042 and 62A.302;
3.24(2) a retiree who is eligible to receive a pension or annuity from the employer and a
3.25covered retiree's spouse, dependent children to the limiting age as defined in section
3.2662Q.01, subdivision 9, disabled children to the extent required in sections 62A.14 and
3.2762A.141, and dependent grandchildren to the extent required in sections 62A.042 and
3.2862A.302;
3.29(3) the surviving spouse, dependent children to the limiting age as defined in section
3.3062Q.01, subdivision 9, disabled children, and dependent grandchildren of a deceased
3.31employee or retiree, if the spouse, children, or grandchildren were covered at the time of
3.32the death;
3.33(4) a covered employee who becomes disabled, as provided in sections 62A.147
3.34and 62A.148; or
4.1(5) any other categories of individuals for whom group coverage is required by
4.2state or federal law.
4.3An employer shall determine when it applies to the program the criteria individuals
4.4in these categories must meet to be eligible for coverage. An employer may subsequently
4.5change the criteria annually, or at other times with approval of the commissioner. The
4.6criteria for dependent children to the limiting age as defined in section 62Q.01, subdivision
4.79, disabled children, and dependent grandchildren may be no more inclusive than the
4.8criteria under section 43A.18, subdivision 2. This paragraph shall not be interpreted
4.9as relieving the program from compliance with any federal and state continuation of
4.10coverage requirements.
4.11(d) Waiver and late entrance. An eligible individual may waive coverage at the
4.12time the employer joins the program or when coverage first becomes available. The
4.13commissioner may establish a preexisting condition exclusion of not more than 18 months
4.14for late entrants as defined in section 62L.02, subdivision 19.
4.15(e) Continuation coverage. The program shall provide all continuation coverage
4.16required by state and federal law.
4.17EFFECTIVE DATE.This section is effective the day following final enactment.

4.18    Sec. 3. Minnesota Statutes 2012, section 60A.08, subdivision 15, is amended to read:
4.19    Subd. 15. Classification of insurance filings data. (a) All forms, rates, and related
4.20information filed with the commissioner under section 61A.02 shall be nonpublic data
4.21until the filing becomes effective.
4.22    (b) All forms, rates, and related information filed with the commissioner under
4.23section 62A.02 shall be nonpublic data until the filing becomes effective.
4.24    (c) All forms, rates, and related information filed with the commissioner under
4.25section 62C.14, subdivision 10, shall be nonpublic data until the filing becomes effective.
4.26    (d) All forms, rates, and related information filed with the commissioner under
4.27section 70A.06 shall be nonpublic data until the filing becomes effective.
4.28    (e) All forms, rates, and related information filed with the commissioner under
4.29section 79.56 shall be nonpublic data until the filing becomes effective.
4.30(f) Notwithstanding paragraphs (b) and (c), for all rate increases subject to review
4.31under section 2794 of the Public Health Services Act and any amendments to, or
4.32regulations, or guidance issued under the act that are filed with the commissioner on or
4.33after September 1, 2011, the commissioner:
4.34(1) may acknowledge receipt of the information;
4.35(2) may acknowledge that the corresponding rate filing is pending review;
5.1(3) must provide public access from the Department of Commerce's Web site to parts
5.2I and II of the Preliminary Justifications of the rate increases subject to review; and
5.3(4) must provide notice to the public on the Department of Commerce's Web site of the
5.4review of the proposed rate, which must include a statement that the public has 30 calendar
5.5days to submit written comments to the commissioner on the rate filing subject to review.
5.6EFFECTIVE DATE.This section is effective the day following final enactment.

5.7    Sec. 4. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision
5.8to read:
5.9    Subd. 1a. Affordable Care Act. "Affordable Care Act" means the federal Patient
5.10Protection and Affordable Care Act, Public Law 111-148, as amended, including the
5.11federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and
5.12any amendments to, and any federal guidance or regulations issued under, these acts.
5.13EFFECTIVE DATE.This section is effective the day following final enactment.

5.14    Sec. 5. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision
5.15to read:
5.16    Subd. 1b. Grandfathered plan. "Grandfathered plan" means a health plan in which
5.17an individual was enrolled on March 23, 2010, for as long as it maintains that status in
5.18accordance with the Affordable Care Act. Unless otherwise specified, grandfathered plans
5.19include both individual and group health plans.
5.20EFFECTIVE DATE.This section is effective the day following final enactment.

5.21    Sec. 6. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision
5.22to read:
5.23    Subd. 1c. Group health plan. "Group health plan" means a policy or certificate
5.24issued to an employer or an employee organization that is both:
5.25(1) a health plan as defined in subdivision 3; and
5.26(2) an employee welfare benefit plan as defined in the Employee Retirement Income
5.27Security Act of 1974, United States Code, title 29, section 1002, if the plan provides
5.28payment for medical care to employees, including both current and former employees, or
5.29their dependents, directly or through insurance, reimbursement, or otherwise, including
5.30employee welfare benefit plans specifically exempt from the provisions of the Employee
5.31Retirement Income Security Act of 1974 under United States Code, title 29, section 1003.
6.1EFFECTIVE DATE.This section is effective the day following final enactment.

6.2    Sec. 7. Minnesota Statutes 2012, section 62A.011, subdivision 3, is amended to read:
6.3    Subd. 3. Health plan. "Health plan" means a policy or certificate of accident and
6.4sickness insurance as defined in section 62A.01 offered by an insurance company licensed
6.5under chapter 60A; a subscriber contract or certificate offered by a nonprofit health
6.6service plan corporation operating under chapter 62C; a health maintenance contract or
6.7certificate offered by a health maintenance organization operating under chapter 62D; a
6.8health benefit certificate offered by a fraternal benefit society operating under chapter
6.964B; or health coverage offered by a joint self-insurance employee health plan operating
6.10under chapter 62H. Health plan means individual and group coverage, unless otherwise
6.11specified. Health plan does not include coverage that is:
6.12(1) limited to disability or income protection coverage;
6.13(2) automobile medical payment coverage;
6.14(3) supplemental liability insurance, including general liability insurance and
6.15automobile liability insurance, or coverage issued as a supplement to liability insurance;
6.16(4) designed solely to provide payments on a per diem, fixed indemnity, or
6.17non-expense-incurred basis, including coverage only for a specified disease or illness or
6.18hospital indemnity or other fixed indemnity insurance, if the benefits are provided under a
6.19separate policy, certificate, or contract for insurance; there is no coordination between the
6.20provision of benefits and any exclusion of benefits under any group health plan maintained
6.21by the same plan sponsor; and the benefits are paid with respect to an event without regard
6.22to whether benefits are provided with respect to such an event under any group health
6.23plan maintained by the same plan sponsor;
6.24(5) credit accident and health insurance as defined in section 62B.02;
6.25(6) designed solely to provide hearing, dental, or vision care;
6.26(7) blanket accident and sickness insurance as defined in section 62A.11;
6.27(8) accident-only coverage;
6.28(9) a long-term care policy as defined in section 62A.46 or 62S.01;
6.29(10) issued as a supplement to Medicare, as defined in sections 62A.3099 to
6.3062A.44 , or policies, contracts, or certificates that supplement Medicare issued by health
6.31maintenance organizations or those policies, contracts, or certificates governed by section
6.321833 or 1876, section 1851, et seq.; or section 1860D-1, et seq., of title XVIII of the
6.33federal Social Security Act, United States Code, title 42, section 1395, et seq., as amended;
6.34(11) workers' compensation insurance; or
7.1(12) issued solely as a companion to a health maintenance contract as described in
7.2section 62D.12, subdivision 1a, so long as the health maintenance contract meets the
7.3definition of a health plan.;
7.4(13) coverage for on-site medical clinics; or
7.5(14) coverage supplemental to the coverage provided under United States Code,
7.6title 10, chapter 55, Civilian Health and Medical Program of the Uniformed Services
7.7(CHAMPUS).
7.8EFFECTIVE DATE.This section is effective the day following final enactment.

7.9    Sec. 8. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision
7.10to read:
7.11    Subd. 4. Individual health plan. "Individual health plan" means a health plan as
7.12defined in subdivision 3 that is offered to individuals in the individual market as defined
7.13in subdivision 5, but does not mean short-term coverage as defined in section 62A.65,
7.14subdivision 7. For purposes of this chapter, a health carrier shall not be deemed to be
7.15offering individual health plan coverage solely because the carrier maintains a conversion
7.16policy in connection with a group health plan.
7.17EFFECTIVE DATE.This section is effective for coverage effective on or after
7.18January 1, 2014.

7.19    Sec. 9. Minnesota Statutes 2012, section 62A.011, is amended by adding a subdivision
7.20to read:
7.21    Subd. 5. Individual market. "Individual market" means the market for health
7.22insurance coverage offered to individuals other than in connection with a group health plan.
7.23EFFECTIVE DATE.This section is effective the day following final enactment.

7.24    Sec. 10. Minnesota Statutes 2012, section 62A.011, is amended by adding a
7.25subdivision to read:
7.26    Subd. 6. Minnesota Insurance Marketplace. "Minnesota Insurance Marketplace"
7.27means the Minnesota Insurance Marketplace as defined in section 62V.02.

7.28    Sec. 11. Minnesota Statutes 2012, section 62A.011, is amended by adding a
7.29subdivision to read:
7.30    Subd. 7. Qualified health plan. "Qualified health plan" means a health plan that
7.31meets the definition in section 1301(a) of the Affordable Care Act and has been certified
8.1by the board of the Minnesota Insurance Marketplace in accordance with chapter 62V to
8.2be offered through the Minnesota Insurance Marketplace.

8.3    Sec. 12. Minnesota Statutes 2012, section 62A.02, is amended by adding a subdivision
8.4to read:
8.5    Subd. 8. Filing by health carriers for purposes of complying with the
8.6certification requirements of the Minnesota Insurance Marketplace. No qualified
8.7health plan shall be offered through the Minnesota Insurance Marketplace until its form
8.8and the premium rates pertaining to the form have been approved by the commissioner of
8.9commerce or health, as appropriate, and the health plan has been determined to comply
8.10with the certification requirements of the Minnesota Insurance Marketplace in accordance
8.11with an agreement between the commissioners of commerce and health and the Minnesota
8.12Insurance Marketplace.
8.13EFFECTIVE DATE.This section is effective for coverage effective on or after
8.14January 1, 2014.

8.15    Sec. 13. Minnesota Statutes 2012, section 62A.03, subdivision 1, is amended to read:
8.16    Subdivision 1. Conditions. No policy of individual accident and sickness insurance
8.17may be delivered or issued for delivery to a person in this state unless:
8.18(1) Premium. The entire money and other considerations therefor are expressed
8.19therein.
8.20(2) Time effective. The time at which the insurance takes effect and terminates is
8.21expressed therein.
8.22(3) One person. It purports to insure only one person, except that a policy may
8.23insure, originally or by subsequent amendment, upon the application of an adult member
8.24of a family deemed the policyholder, any two or more eligible members of that family,
8.25including:
8.26(a) husband,
8.27(b) wife,
8.28(c) dependent children as described in sections 62A.302 and 62A.3021, or
8.29(d) any children under a specified age of 19 years or less, or
8.30(e) (d) any other person dependent upon the policyholder.
8.31(4) Appearance. The style, arrangement, and overall appearance of the policy give
8.32no undue prominence to any portion of the text and every printed portion of the text of the
8.33policy and of any endorsements or attached papers is plainly printed in light-face type
8.34of a style in general use. The type size must be uniform and not less than ten point with
9.1a lowercase unspaced alphabet length not less than 120 point. The "text" includes all
9.2printed matter except the name and address of the insurer, name or title of the policy, the
9.3brief description, if any, the reference to renewal or cancellation by a separate statement,
9.4if any, and the captions and subcaptions.
9.5(5) Description of policy. The policy, on the first page, indicates or refers to its
9.6provisions for renewal or cancellation either in the brief description, if any, or by a separate
9.7statement printed in type not smaller than the type used for captions or a separate provision
9.8bearing a caption which accurately describes the renewability or cancelability of the policy.
9.9(6) Exceptions in policy. The exceptions and reductions of indemnity are set
9.10forth in the policy and, except those which are set forth in section 62A.04, printed, at
9.11the insurer's option, either with the benefit provision to which they apply, or under an
9.12appropriate caption such as "EXCEPTIONS" or "EXCEPTIONS AND REDUCTIONS."
9.13However, if an exception or reduction specifically applies only to a particular benefit of
9.14the policy, a statement of the exception or reduction must be included with the benefit
9.15provision to which it applies.
9.16(7) Form number. Each form, including riders and endorsements, is identified by a
9.17form number in the lower left hand corner of the first page thereof.
9.18(8) No incorporation by reference. It contains no provision purporting to make
9.19any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy
9.20unless the portion is set forth in full in the policy, except in the case of the incorporation
9.21of, or reference to, a statement of rates, classification of risks, or short rate table filed
9.22with the commissioner.
9.23(9) Medical benefits. If the policy contains a provision for medical expense benefits,
9.24the term "medical benefits" or similar terms as used therein includes treatments by all
9.25licensed practitioners of the healing arts unless, subject to the qualifications contained in
9.26clause (10), the policy specifically states the practitioners whose services are covered.
9.27(10) Osteopath, optometrist, chiropractor, or registered nurse services. With
9.28respect to any policy of individual accident and sickness insurance issued or entered
9.29into subsequent to August 1, 1974, notwithstanding the provisions of the policy, if it
9.30contains a provision providing for reimbursement for any service which is in the lawful
9.31scope of practice of a duly licensed osteopath, optometrist, chiropractor, or registered
9.32nurse meeting the requirements of section 62A.15, subdivision 3a, the person entitled to
9.33benefits or person performing services under the policy is entitled to reimbursement on an
9.34equal basis for the service, whether the service is performed by a physician, osteopath,
9.35optometrist, chiropractor, or registered nurse meeting the requirements of section 62A.15,
9.36subdivision 3a
, licensed under the laws of this state.
10.1EFFECTIVE DATE.This section is effective the day following final enactment.

10.2    Sec. 14. Minnesota Statutes 2012, section 62A.04, subdivision 2, is amended to read:
10.3    Subd. 2. Required provisions. Except as provided in subdivision 4 each such
10.4policy delivered or issued for delivery to any person in this state shall contain the
10.5provisions specified in this subdivision in the words in which the same appear in this
10.6section. The insurer may, at its option, substitute for one or more of such provisions
10.7corresponding provisions of different wording approved by the commissioner which are
10.8in each instance not less favorable in any respect to the insured or the beneficiary. Such
10.9provisions shall be preceded individually by the caption appearing in this subdivision or, at
10.10the option of the insurer, by such appropriate individual or group captions or subcaptions
10.11as the commissioner may approve.
10.12(1) A provision as follows:
10.13ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and
10.14the attached papers, if any, constitutes the entire contract of insurance. No change in this
10.15policy shall be valid until approved by an executive officer of the insurer and unless such
10.16approval be endorsed hereon or attached hereto. No agent has authority to change this
10.17policy or to waive any of its provisions.
10.18(2) A provision as follows:
10.19TIME LIMIT ON CERTAIN DEFENSES: (a) After two years from the date of issue
10.20of this policy no misstatements, except fraudulent misstatements, made by the applicant
10.21in the application for such policy shall be used to void the policy or to deny a claim for
10.22loss incurred or disability (as defined in the policy) commencing after the expiration
10.23of such two year period.
10.24The foregoing policy provision shall not be so construed as to affect any legal
10.25requirement for avoidance of a policy or denial of a claim during such initial two year
10.26period, nor to limit the application of clauses (1), (2), (3), (4) and (5), in the event of
10.27misstatement with respect to age or occupation or other insurance. A policy which the
10.28insured has the right to continue in force subject to its terms by the timely payment of
10.29premium (1) until at least age 50 or, (2) in the case of a policy issued after age 44, for at
10.30least five years from its date of issue, may contain in lieu of the foregoing the following
10.31provisions (from which the clause in parentheses may be omitted at the insurer's option)
10.32under the caption "INCONTESTABLE":
10.33After this policy has been in force for a period of two years during the lifetime of
10.34the insured (excluding any period during which the insured is disabled), it shall become
10.35incontestable as to the statements contained in the application.
11.1(b) No claim for loss incurred or disability (as defined in the policy) commencing after
11.2two years from the date of issue of this policy shall be reduced or denied on the ground that
11.3a disease or physical condition not excluded from coverage by name or specific description
11.4effective on the date of loss had existed prior to the effective date of coverage of this policy.
11.5(3)(a) Except as required for qualified health plans sold through the Minnesota
11.6Insurance Marketplace to individuals receiving advance payments of the premium tax
11.7credit, a provision as follows:
11.8GRACE PERIOD: A grace period of ..... (insert a number not less than "7" for
11.9weekly premium policies, "10" for monthly premium policies and "31" for all other
11.10policies) days will be granted for the payment of each premium falling due after the first
11.11premium, during which grace period the policy shall continue in force.
11.12A policy which contains a cancellation provision may add, at the end of the above
11.13provision,
11.14subject to the right of the insurer to cancel in accordance with the cancellation
11.15provision hereof.
11.16A policy in which the insurer reserves the right to refuse any renewal shall have,
11.17at the beginning of the above provision,
11.18Unless not less than five days prior to the premium due date the insurer has delivered
11.19to the insured or has mailed to the insured's last address as shown by the records of the
11.20insurer written notice of its intention not to renew this policy beyond the period for which
11.21the premium has been accepted.
11.22(b) For qualified health plans sold through the Minnesota Insurance Marketplace
11.23to individuals receiving advance payments of the premium tax credit, a grace period
11.24provision must be included that complies with the Affordable Care Act and is no less
11.25restrictive than the grace period required by the Affordable Care Act.
11.26(4) A provision as follows:
11.27REINSTATEMENT: If any renewal premium be not paid within the time granted the
11.28insured for payment, a subsequent acceptance of premium by the insurer or by any agent
11.29duly authorized by the insurer to accept such premium, without requiring in connection
11.30therewith an application for reinstatement, shall reinstate the policy. If the insurer or
11.31such agent requires an application for reinstatement and issues a conditional receipt for
11.32the premium tendered, the policy will be reinstated upon approval of such application
11.33by the insurer or, lacking such approval, upon the forty-fifth day following the date of
11.34such conditional receipt unless the insurer has previously notified the insured in writing
11.35of its disapproval of such application. For health plans described in section 62A.011,
11.36subdivision 3
, clause (10), an insurer must accept payment of a renewal premium and
12.1reinstate the policy, if the insured applies for reinstatement no later than 60 days after the
12.2due date for the premium payment, unless:
12.3(1) the insured has in the interim left the state or the insurer's service area; or
12.4(2) the insured has applied for reinstatement on two or more prior occasions.
12.5The reinstated policy shall cover only loss resulting from such accidental injury as
12.6may be sustained after the date of reinstatement and loss due to such sickness as may
12.7begin more than ten days after such date. In all other respects the insured and insurer shall
12.8have the same rights thereunder as they had under the policy immediately before the due
12.9date of the defaulted premium, subject to any provisions endorsed hereon or attached
12.10hereto in connection with the reinstatement. Any premium accepted in connection with
12.11a reinstatement shall be applied to a period for which premium has not been previously
12.12paid, but not to any period more than 60 days prior to the date of reinstatement. The last
12.13sentence of the above provision may be omitted from any policy which the insured has
12.14the right to continue in force subject to its terms by the timely payment of premiums
12.15(1) until at least age 50, or, (2) in the case of a policy issued after age 44, for at least
12.16five years from its date of issue.
12.17(5) A provision as follows:
12.18NOTICE OF CLAIM: Written notice of claim must be given to the insurer within
12.1920 days after the occurrence or commencement of any loss covered by the policy, or as
12.20soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or
12.21the beneficiary to the insurer at ..... (insert the location of such office as the insurer may
12.22designate for the purpose), or to any authorized agent of the insurer, with information
12.23sufficient to identify the insured, shall be deemed notice to the insurer.
12.24In a policy providing a loss-of-time benefit which may be payable for at least two
12.25years, an insurer may at its option insert the following between the first and second
12.26sentences of the above provision:
12.27Subject to the qualifications set forth below, if the insured suffers loss of time on
12.28account of disability for which indemnity may be payable for at least two years, the
12.29insured shall, at least once in every six months after having given notice of claim, give to
12.30the insurer notice of continuance of said disability, except in the event of legal incapacity.
12.31The period of six months following any filing of proof by the insured or any payment by
12.32the insurer on account of such claim or any denial of liability in whole or in part by the
12.33insurer shall be excluded in applying this provision. Delay in the giving of such notice
12.34shall not impair the insured's right to any indemnity which would otherwise have accrued
12.35during the period of six months preceding the date on which such notice is actually given.
12.36(6) A provision as follows:
13.1CLAIM FORMS: The insurer, upon receipt of a notice of claim, will furnish to the
13.2claimant such forms as are usually furnished by it for filing proofs of loss. If such forms
13.3are not furnished within 15 days after the giving of such notice the claimant shall be
13.4deemed to have complied with the requirements of this policy as to proof of loss upon
13.5submitting, within the time fixed in the policy for filing proofs of loss, written proof
13.6covering the occurrence, the character and the extent of the loss for which claim is made.
13.7(7) A provision as follows:
13.8PROOFS OF LOSS: Written proof of loss must be furnished to the insurer at its
13.9said office in case of claim for loss for which this policy provides any periodic payment
13.10contingent upon continuing loss within 90 days after the termination of the period for
13.11which the insurer is liable and in case of claim for any other loss within 90 days after the
13.12date of such loss. Failure to furnish such proof within the time required shall not invalidate
13.13nor reduce any claim if it was not reasonably possible to give proof within such time,
13.14provided such proof is furnished as soon as reasonably possible and in no event, except in
13.15the absence of legal capacity, later than one year from the time proof is otherwise required.
13.16(8) A provision as follows:
13.17TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy for
13.18any loss other than loss for which this policy provides periodic payment will be paid
13.19immediately upon receipt of due written proof of such loss. Subject to due written proof
13.20of loss, all accrued indemnities for loss for which this policy provides periodic payment
13.21will be paid ..... (insert period for payment which must not be less frequently than
13.22monthly) and any balance remaining unpaid upon the termination of liability will be paid
13.23immediately upon receipt of due written proof.
13.24(9) A provision as follows:
13.25PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance
13.26with the beneficiary designation and the provisions respecting such payment which may
13.27be prescribed herein and effective at the time of payment. If no such designation or
13.28provision is then effective, such indemnity shall be payable to the estate of the insured.
13.29Any other accrued indemnities unpaid at the insured's death may, at the option of the
13.30insurer, be paid either to such beneficiary or to such estate. All other indemnities will
13.31be payable to the insured.
13.32The following provisions, or either of them, may be included with the foregoing
13.33provision at the option of the insurer:
13.34If any indemnity of this policy shall be payable to the estate of the insured, or to an
13.35insured or beneficiary who is a minor or otherwise not competent to give a valid release,
13.36the insurer may pay such indemnity, up to an amount not exceeding $..... (insert an amount
14.1which shall not exceed $1,000), to any relative by blood or connection by marriage of the
14.2insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any
14.3payment made by the insurer in good faith pursuant to this provision shall fully discharge
14.4the insurer to the extent of such payment.
14.5Subject to any written direction of the insured in the application or otherwise all
14.6or a portion of any indemnities provided by this policy on account of hospital, nursing,
14.7medical, or surgical services may, at the insurer's option and unless the insured requests
14.8otherwise in writing not later than the time of filing proofs of such loss, be paid directly to
14.9the hospital or person rendering such services; but it is not required that the service be
14.10rendered by a particular hospital or person.
14.11(10) A provision as follows:
14.12PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense
14.13shall have the right and opportunity to examine the person of the insured when and as
14.14often as it may reasonably require during the pendency of a claim hereunder and to make
14.15an autopsy in case of death where it is not forbidden by law.
14.16(11) A provision as follows:
14.17LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this
14.18policy prior to the expiration of 60 days after written proof of loss has been furnished in
14.19accordance with the requirements of this policy. No such action shall be brought after the
14.20expiration of three years after the time written proof of loss is required to be furnished.
14.21(12) A provision as follows:
14.22CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable designation
14.23of beneficiary, the right to change of beneficiary is reserved to the insured and the consent
14.24of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of
14.25this policy or to any change of beneficiary or beneficiaries, or to any other changes in
14.26this policy. The first clause of this provision, relating to the irrevocable designation of
14.27beneficiary, may be omitted at the insurer's option.
14.28EFFECTIVE DATE.This section is effective January 1, 2014.

14.29    Sec. 15. Minnesota Statutes 2012, section 62A.047, is amended to read:
14.3062A.047 CHILDREN'S HEALTH SUPERVISION SERVICES AND
14.31PRENATAL CARE SERVICES.
14.32A policy of individual or group health and accident insurance regulated under this
14.33chapter, or individual or group subscriber contract regulated under chapter 62C, health
14.34maintenance contract regulated under chapter 62D, or health benefit certificate regulated
15.1under chapter 64B, issued, renewed, or continued to provide coverage to a Minnesota
15.2resident, must provide coverage for child health supervision services and prenatal care
15.3services. The policy, contract, or certificate must specifically exempt reasonable and
15.4customary charges for child health supervision services and prenatal care services from a
15.5deductible, co-payment, or other coinsurance or dollar limitation requirement. Nothing
15.6in this section prohibits a health carrier that has a network of providers from imposing
15.7a deductible, co-payment, or other coinsurance or dollar limitation requirement for
15.8child health supervision services and prenatal care services that are delivered by an
15.9out-of-network provider. This section does not prohibit the use of policy waiting periods
15.10or preexisting condition limitations for these services. Minimum benefits may be limited
15.11to one visit payable to one provider for all of the services provided at each visit cited in
15.12this section subject to the schedule set forth in this section. Nothing in this section applies
15.13to a policy designed primarily to provide coverage payable on a per diem, fixed indemnity,
15.14or non-expense-incurred basis, or a policy that provides only accident coverage. A policy,
15.15contract, or certificate described under this section may not apply to preexisting condition
15.16limitations to individuals under 19 years of age. This section does not apply to individual
15.17coverage under a grandfathered plan.
15.18"Child health supervision services" means pediatric preventive services, appropriate
15.19immunizations, developmental assessments, and laboratory services appropriate to the age
15.20of a child from birth to age six, and appropriate immunizations from ages six to 18, as
15.21defined by Standards of Child Health Care issued by the American Academy of Pediatrics.
15.22Reimbursement must be made for at least five child health supervision visits from birth
15.23to 12 months, three child health supervision visits from 12 months to 24 months, once a
15.24year from 24 months to 72 months.
15.25"Prenatal care services" means the comprehensive package of medical and
15.26psychosocial support provided throughout the pregnancy, including risk assessment,
15.27serial surveillance, prenatal education, and use of specialized skills and technology,
15.28when needed, as defined by Standards for Obstetric-Gynecologic Services issued by the
15.29American College of Obstetricians and Gynecologists.
15.30EFFECTIVE DATE.This section is effective the day following final enactment.

15.31    Sec. 16. Minnesota Statutes 2012, section 62A.049, is amended to read:
15.3262A.049 LIMITATION ON PREAUTHORIZATIONS; EMERGENCIES.
15.33No policy of accident and sickness insurance or group subscriber contract regulated
15.34under chapter 62C issued or renewed in this state may contain a provision that makes an
16.1insured person ineligible to receive full benefits because of the insured's failure to obtain
16.2preauthorization, if that failure occurs because of the need for emergency confinement
16.3or emergency treatment. The insured or an authorized representative of the insured shall
16.4notify the insurer as soon after the beginning of emergency confinement or emergency
16.5treatment as reasonably possible. However, to the extent that the insurer suffers actual
16.6prejudice caused by the failure to obtain preauthorization, the insured may be denied all or
16.7part of the insured's benefits. This provision does not apply to admissions for treatment of
16.8chemical dependency and nervous and mental disorders.
16.9EFFECTIVE DATE.This section is effective January 1, 2014.

16.10    Sec. 17. Minnesota Statutes 2012, section 62A.136, is amended to read:
16.1162A.136 HEARING, DENTAL, AND VISION PLAN COVERAGE.
16.12The following provisions do not apply to health plans as defined in section 62A.011,
16.13subdivision 3
, clause (6), providing hearing, dental, or vision coverage only: sections
16.1462A.041 ; 62A.0411; 62A.047; 62A.149; 62A.151; 62A.152; 62A.154; 62A.155; 62A.17,
16.15subdivision 6
; 62A.21, subdivision 2b; 62A.26; 62A.28; 62A.285; 62A.30; 62A.304; and
16.16 62A.3093; and 62E.16.
16.17EFFECTIVE DATE.This section is effective January 1, 2014.

16.18    Sec. 18. Minnesota Statutes 2012, section 62A.149, subdivision 1, is amended to read:
16.19    Subdivision 1. Application. The provisions of this section apply to all group
16.20policies of accident and health insurance and group subscriber contracts offered by
16.21nonprofit health service plan corporations regulated under chapter 62C, and to a plan or
16.22policy that is individually underwritten or provided for a specific individual and family
16.23members as a nongroup policy unless the individual elects in writing to refuse benefits
16.24under this subdivision in exchange for an appropriate reduction in premiums or subscriber
16.25charges under the policy or plan, when the policies or subscriber contracts are issued or
16.26delivered in Minnesota or provide benefits to Minnesota residents enrolled thereunder.
16.27    This section does not apply to policies designed primarily to provide coverage
16.28payable on a per diem, fixed indemnity or nonexpense incurred basis or policies that
16.29provide accident only coverage.
16.30    Every insurance policy or subscriber contract included within the provisions of this
16.31subdivision, upon issuance or renewal, shall provide coverage that complies with the
16.32requirements of section 62Q.47, paragraphs (b) and (c), for the treatment of alcoholism,
16.33chemical dependency or drug addiction to any Minnesota resident entitled to coverage.
17.1EFFECTIVE DATE.This section is effective January 1, 2014.

17.2    Sec. 19. Minnesota Statutes 2012, section 62A.17, subdivision 2, is amended to read:
17.3    Subd. 2. Responsibility of employee. Every covered employee electing to continue
17.4coverage shall pay the former employer, on a monthly basis, the cost of the continued
17.5coverage. The policy, contract, or plan must require the group policyholder or contract
17.6holder to, upon request, provide the employee with written verification from the insurer
17.7of the cost of this coverage promptly at the time of eligibility for this coverage and at
17.8any time during the continuation period. If the policy, contract, or health care plan is
17.9administered by a trust, every covered employee electing to continue coverage shall pay
17.10the trust the cost of continued coverage according to the eligibility rules established by the
17.11trust. In no event shall the amount of premium charged exceed 102 percent of the cost
17.12to the plan for such period of coverage for similarly situated employees with respect to
17.13whom neither termination nor layoff has occurred, without regard to whether such cost
17.14is paid by the employer or employee. The employee shall be eligible to continue the
17.15coverage until the employee becomes covered under another group health plan, or for a
17.16period of 18 months after the termination of or lay off from employment, whichever is
17.17shorter. For an individual age 19 or older, if the employee becomes covered under another
17.18group policy, contract, or health plan and the new group policy, contract, or health plan
17.19contains any preexisting condition limitations, the employee may, subject to the 18-month
17.20maximum continuation limit, continue coverage with the former employer until the
17.21preexisting condition limitations have been satisfied. The new policy, contract, or health
17.22plan is primary except as to the preexisting condition. In the case of a newborn child who
17.23is a dependent of the employee, the new policy, contract, or health plan is primary upon
17.24the date of birth of the child, regardless of which policy, contract, or health plan coverage
17.25is deemed primary for the mother of the child.
17.26EFFECTIVE DATE.This section is effective the day following final enactment.

17.27    Sec. 20. Minnesota Statutes 2012, section 62A.17, subdivision 6, is amended to read:
17.28    Subd. 6. Conversion to individual policy. A group insurance policy that provides
17.29posttermination or layoff coverage as required by this section shall also include a
17.30provision allowing a covered employee, surviving spouse, or dependent at the expiration
17.31of the posttermination or layoff coverage provided by subdivision 2 to obtain from the
17.32insurer offering the group policy or group subscriber contract, at the employee's, spouse's,
17.33or dependent's option and expense, without further evidence of insurability and without
17.34interruption of coverage, an individual policy of insurance or an individual subscriber
18.1contract providing at least the minimum benefits of a qualified plan as prescribed by
18.2section 62E.06 and the option of a number three qualified plan, a number two qualified
18.3plan, and a number one qualified plan as provided by section 62E.06, subdivisions 1 to
18.43, provided application is made to the insurer within 30 days following notice of the
18.5expiration of the continued coverage and upon payment of the appropriate premium.
18.6The required conversion contract must treat pregnancy the same as any other covered
18.7illness under the conversion contract. A health maintenance contract issued by a health
18.8maintenance organization that provides posttermination or layoff coverage as required
18.9by this section shall also include a provision allowing a former employee, surviving
18.10spouse, or dependent at the expiration of the posttermination or layoff coverage provided
18.11in subdivision 2 to obtain from the health maintenance organization, at the former
18.12employee's, spouse's, or dependent's option and expense, without further evidence of
18.13insurability and without interruption of coverage, an individual health maintenance
18.14contract. Effective January 1, 1985, enrollees who have become nonresidents of the health
18.15maintenance organization's service area shall be given the option, to be arranged by the
18.16health maintenance organization, of a number three qualified plan, a number two qualified
18.17plan, or a number one qualified plan as provided by section 62E.06, subdivisions 1 to 3.
18.18This option shall be made available at the enrollee's expense, without further evidence of
18.19insurability and without interruption of coverage.
18.20A policy providing reduced benefits at a reduced premium rate may be accepted
18.21by the employee, the spouse, or a dependent in lieu of the optional coverage otherwise
18.22required by this subdivision.
18.23The An individual policy or contract issued as a conversion policy prior to January
18.241, 2014, shall be renewable at the option of the individual as long as the individual is not
18.25covered under another qualified plan as defined in section 62E.02, subdivision 4. Any
18.26revisions in the table of rate for the individual policy shall apply to the covered person's
18.27original age at entry and shall apply equally to all similar conversion policies issued
18.28by the insurer.
18.29EFFECTIVE DATE.This section is effective January 1, 2014.

18.30    Sec. 21. Minnesota Statutes 2012, section 62A.21, subdivision 2b, is amended to read:
18.31    Subd. 2b. Conversion privilege. Every policy described in subdivision 1 shall
18.32contain a provision allowing a former spouse and dependent children of an insured,
18.33without providing evidence of insurability, to obtain from the insurer at the expiration of
18.34any continuation of coverage required under subdivision 2a or sections 62A.146 and
18.3562A.20, conversion coverage providing at least the minimum benefits of a qualified
19.1plan as prescribed by section 62E.06 and the option of a number three qualified plan, a
19.2number two qualified plan, a number one qualified plan as provided by section 62E.06,
19.3subdivisions 1 to 3, provided application is made to the insurer within 30 days following
19.4notice of the expiration of the continued coverage and upon payment of the appropriate
19.5premium. The An individual policy or contract issued as a conversion policy prior to
19.6January 1, 2014, shall be renewable at the option of the covered person as long as the
19.7covered person is not covered under another qualified plan as defined in section 62E.02,
19.8subdivision 4
. Any revisions in the table of rate for the individual policy shall apply to the
19.9covered person's original age at entry and shall apply equally to all similar conversion
19.10 policies issued by the insurer.
19.11A policy providing reduced benefits at a reduced premium rate may be accepted by
19.12the covered person in lieu of the optional coverage otherwise required by this subdivision.
19.13EFFECTIVE DATE.This section is effective January 1, 2014.

19.14    Sec. 22. Minnesota Statutes 2012, section 62A.28, subdivision 2, is amended to read:
19.15    Subd. 2. Required coverage. Every policy, plan, certificate, or contract referred to
19.16in subdivision 1 issued or renewed after August 1, 1987, must provide coverage for scalp
19.17hair prostheses worn for hair loss suffered as a result of alopecia areata.
19.18The coverage required by this section is subject to the co-payment, coinsurance,
19.19deductible, and other enrollee cost-sharing requirements that apply to similar types of
19.20items under the policy, plan, certificate, or contract, and is limited to a maximum of $350
19.21in any benefit year and may be limited to one prosthesis per benefit year.
19.22EFFECTIVE DATE.This section is effective January 1, 2014.

19.23    Sec. 23. Minnesota Statutes 2012, section 62A.302, is amended to read:
19.2462A.302 COVERAGE OF DEPENDENTS.
19.25    Subdivision 1. Scope of coverage. This section applies to:
19.26(1) a health plan as defined in section 62A.011; and
19.27(2) coverage described in section 62A.011, subdivision 3, clauses (4), (6), (7), (8),
19.28(9), and (10); and
19.29(3) (2) a policy, contract, or certificate issued by a community integrated service
19.30network licensed under chapter 62N.
19.31    Subd. 2. Required coverage. Every health plan included in subdivision 1 that
19.32provides dependent coverage must define "dependent" no more restrictively than the
19.33definition provided in section 62L.02, subdivision 11.
20.1    Subd. 3. No additional restrictions permitted. Any health plan included in
20.2subdivision 1 that provides dependent coverage of children shall make that coverage
20.3available to children until the child attains 26 years of age. A health carrier must not place
20.4restrictions on this coverage and must comply with the following requirements:
20.5(1) with respect to a child who has not attained 26 years of age, a health carrier shall
20.6not define dependent for purposes of eligibility for dependent coverage of children other
20.7than the terms of a relationship between a child and the enrollee or spouse of the enrollee;
20.8(2) a health carrier must not deny or restrict coverage for a child who has not attained
20.926 years of age based on (i) the presence or absence of the child's financial dependency upon
20.10the participant, primary subscriber, or any other person; (ii) residency with the participant
20.11and in the individual market the primary subscriber, or with any other person; (iii) marital
20.12status; (iv) student status; (v) employment; or (vi) any combination of those factors; and
20.13(3) a health carrier must not deny or restrict coverage of a child based on eligibility
20.14for other coverage, except as provided in subdivision 5.
20.15    Subd. 4. Grandchildren. Nothing in this section requires a health carrier to make
20.16coverage available for a grandchild, unless the grandparent becomes the legal guardian
20.17or adoptive parent of that grandchild or unless the grandchild meets the requirements
20.18of section 62A.042. For grandchildren included under a grandparent's policy pursuant
20.19to section 62A.042, coverage for the grandchild may terminate if the grandchild does
20.20not continue to reside with the covered grandparent continuously from birth, if the
20.21grandchild does not remain financially dependent upon the covered grandparent, or when
20.22the grandchild reaches age 25, except as provided in section 62A.14 or if coverage is
20.23continued under section 62A.20.
20.24    Subd. 5. Terms of coverage of dependents. The terms of coverage in a health plan
20.25offered by a health carrier providing dependent coverage of children cannot vary based on
20.26age except for children who are 26 years of age or older.
20.27    Subd. 6. Opportunity to enroll. A health carrier must comply with all provisions
20.28of the Affordable Care Act in regards to providing an opportunity to enroll in coverage to
20.29any child whose coverage ended, or was not eligible for coverage under a group health
20.30plan or individual health plan because, under the terms of the coverage, the availability of
20.31dependent coverage of a child ended before age 26.
20.32    Subd. 7. Grandfathered plan coverage. (a) For plan years beginning before
20.33January 1, 2014, a group health plan that is a grandfathered plan and makes available
20.34dependent coverage of children may exclude an adult child who has not attained 26
20.35years of age from coverage only if the adult child is eligible to enroll in an eligible
21.1employer-sponsored health benefit plan, as defined in section 5000A(f)(2) of the Internal
21.2Revenue Code, other than the group health plan of a parent.
21.3(b) For plan years beginning on or after January 1, 2014, a group health plan that is a
21.4grandfathered plan must comply with all requirements of this section.
21.5    Subd. 8. Compliance. This section does not require compliance with any provision
21.6of the Affordable Care Act before the effective date provided for that provision in the
21.7Affordable Care Act.
21.8    Subd. 9. Enforcement. The commissioner shall enforce this section.
21.9EFFECTIVE DATE.This section is effective the day following final enactment.

21.10    Sec. 24. [62A.3021] COVERAGE OF DEPENDENTS BY PLANS OTHER THAN
21.11HEALTH PLANS.
21.12    Subdivision 1. Scope of coverage. This section applies to coverage described in
21.13section 62A.011, subdivision 3, clauses (4), (6), (7), (8), (9), and (10).
21.14    Subd. 2. Dependent. "Dependent" means an eligible employee's spouse, unmarried
21.15child who is under the age of 25, dependent child of any age who is disabled and who
21.16meets the eligibility criteria in section 62A.14, subdivision 2, or any other person whom
21.17state or federal law requires to be treated as a dependent for purposes of health plans. For
21.18the purpose of this definition, a child includes a child for whom the employee or the
21.19employee's spouse has been appointed legal guardian and an adoptive child as provided in
21.20section 62A.27. A child also includes grandchildren as provided in section 62A.042 with
21.21continued eligibility of grandchildren as provided in section 62A.302, subdivision 4.
21.22EFFECTIVE DATE.This section is effective the day following final enactment.

21.23    Sec. 25. Minnesota Statutes 2012, section 62A.615, is amended to read:
21.2462A.615 PREEXISTING CONDITIONS DISCLOSED AT TIME OF
21.25APPLICATION.
21.26No insurer may cancel or rescind a health insurance policy for a preexisting condition
21.27of which the application or other information provided by the insured reasonably gave
21.28the insurer notice. No insurer may restrict coverage for a preexisting condition of which
21.29the application or other information provided by the insured reasonably gave the insurer
21.30notice unless the coverage is restricted at the time the policy is issued and the restriction is
21.31disclosed in writing to the insured at the time the policy is issued. In addition, no health plan
21.32may restrict coverage for a preexisting condition for an individual who is under 19 years
21.33of age. This section does not apply to individual health plans that are grandfathered plans.
22.1EFFECTIVE DATE.This section is effective the day following final enactment.

22.2    Sec. 26. Minnesota Statutes 2012, section 62A.65, subdivision 3, is amended to read:
22.3    Subd. 3. Premium rate restrictions. No individual health plan may be offered,
22.4sold, issued, or renewed to a Minnesota resident unless the premium rate charged is
22.5determined in accordance with the following requirements:
22.6(a) Premium rates must be no more than 25 percent above and no more than 25
22.7percent below the index rate charged to individuals for the same or similar coverage,
22.8adjusted pro rata for rating periods of less than one year. The premium variations
22.9permitted by this paragraph must be based only upon health status, claims experience,
22.10and occupation. For purposes of this paragraph, health status includes refraining from
22.11tobacco use or other actuarially valid lifestyle factors associated with good health,
22.12provided that the lifestyle factor and its effect upon premium rates have been determined
22.13by the commissioner to be actuarially valid and have been approved by the commissioner.
22.14Variations permitted under this paragraph must not be based upon age or applied
22.15differently at different ages. This paragraph does not prohibit use of a constant percentage
22.16adjustment for factors permitted to be used under this paragraph.
22.17(b) (a) Premium rates may vary based upon the ages of covered persons only as
22.18provided in this paragraph. In addition to the variation permitted under paragraph (a), each
22.19health carrier may use an additional premium variation based upon age of up to plus or
22.20minus 50 percent of the index rate in accordance with the provisions of the Affordable
22.21Care Act.
22.22(c) A health carrier may request approval by the commissioner to establish separate
22.23geographic regions determined by the health carrier and to establish separate index rates
22.24for each such region.
22.25(b) Premium rates may vary based upon geographic rating area. The commissioner
22.26shall grant approval if the following conditions are met:
22.27(1) the geographic regions must be applied uniformly by the health carrier the areas
22.28are established in accordance with the Affordable Care Act;
22.29(2) each geographic region must be composed of no fewer than seven counties that
22.30create a contiguous region; and
22.31(3) the health carrier provides actuarial justification acceptable to the commissioner
22.32for the proposed geographic variations in index rates premium rates for each area,
22.33establishing that the variations are based upon differences in the cost to the health carrier
22.34of providing coverage.
23.1(d) Health carriers may use rate cells and must file with the commissioner the rate
23.2cells they use. Rate cells must be based upon the number of adults or children covered
23.3under the policy and may reflect the availability of Medicare coverage. The rates for
23.4different rate cells must not in any way reflect generalized differences in expected costs
23.5between principal insureds and their spouses.
23.6(c) Premium rates may vary based upon tobacco use, in accordance with the
23.7provisions of the Affordable Care Act.
23.8(e) (d) In developing its index rates and premiums for a health plan, a health carrier
23.9shall take into account only the following factors:
23.10(1) actuarially valid differences in rating factors permitted under paragraphs (a)
23.11and (b) (c); and
23.12(2) actuarially valid geographic variations if approved by the commissioner as
23.13provided in paragraph (c) (b).
23.14(e) The premium charged with respect to any particular individual health plan shall
23.15not be adjusted more frequently than annually or January 1 of the year following initial
23.16enrollment, except that the premium rates may be changed to reflect:
23.17(1) changes to the family composition of the policyholder;
23.18(2) changes in geographic rating area of the policyholder, as provided in paragraph
23.19(b);
23.20(3) changes in age, as provided in paragraph (a);
23.21(4) changes in tobacco use, as provided in paragraph (c);
23.22(5) transfer to a new health plan requested by the policyholder; or
23.23(6) other changes required by or otherwise expressly permitted by state or federal
23.24law or regulations.
23.25(f) All premium variations must be justified in initial rate filings and upon request of
23.26the commissioner in rate revision filings. All rate variations are subject to approval by
23.27the commissioner.
23.28(g) The loss ratio must comply with the section 62A.021 requirements for individual
23.29health plans.
23.30(h) The rates must not be approved, unless the commissioner has determined that the
23.31rates are reasonable. In determining reasonableness, the commissioner shall consider the
23.32growth rates applied under section 62J.04, subdivision 1, paragraph (b), to the calendar
23.33year or years that the proposed premium rate would be in effect, and actuarially valid
23.34changes in risks associated with the enrollee populations, and actuarially valid changes as
23.35a result of statutory changes in Laws 1992, chapter 549.
24.1(i) An insurer A health carrier may, as part of a minimum lifetime loss ratio
24.2guarantee filing under section 62A.02, subdivision 3a, include a rating practices guarantee
24.3as provided in this paragraph. The rating practices guarantee must be in writing and
24.4must guarantee that the policy form will be offered, sold, issued, and renewed only with
24.5premium rates and premium rating practices that comply with subdivisions 2, 3, 4, and 5.
24.6The rating practices guarantee must be accompanied by an actuarial memorandum that
24.7demonstrates that the premium rates and premium rating system used in connection with
24.8the policy form will satisfy the guarantee. The guarantee must guarantee refunds of any
24.9excess premiums to policyholders charged premiums that exceed those permitted under
24.10subdivision 2, 3, 4, or 5. An insurer A health carrier that complies with this paragraph in
24.11connection with a policy form is exempt from the requirement of prior approval by the
24.12commissioner under paragraphs (c) (b), (f), and (h).
24.13(j) The commissioner may establish regulations to implement the provisions of
24.14this subdivision.
24.15EFFECTIVE DATE.This section is effective January 1, 2014.

24.16    Sec. 27. Minnesota Statutes 2012, section 62A.65, is amended by adding a subdivision
24.17to read:
24.18    Subd. 3a. Disclosure. (a) In connection with the offering for sale of a health plan
24.19in the individual market, a health carrier shall make a reasonable disclosure, as part of
24.20its solicitation and sales materials, of all of the following:
24.21(1) the provisions of the coverage concerning the health carrier's right to change
24.22premium rates and the factors that may affect changes in premium rates; and
24.23(2) a listing of and descriptive information, including benefits and premiums, about
24.24all individual health plans actively marketed by the health carrier and the availability of
24.25the individual health plans for which the individual is qualified.
24.26(b) Paragraph (a), clause (1), may be satisfied by referring individuals to the Health
24.27and Human Services Web portal, as defined under the Affordable Care Act.

24.28    Sec. 28. Minnesota Statutes 2012, section 62A.65, is amended by adding a subdivision
24.29to read:
24.30    Subd. 3b. Single risk pool. A health carrier shall consider all enrollees in all health
24.31plans, other than short-term and grandfathered plan coverage, offered by the health carrier
24.32in the individual market, including those enrollees who enroll in qualified health plans
24.33offered through the Minnesota Insurance Marketplace, to be members of a single risk pool.

25.1    Sec. 29. Minnesota Statutes 2012, section 62A.65, subdivision 5, is amended to read:
25.2    Subd. 5. Portability and conversion of coverage. (a) For plan years beginning
25.3on or after January 1, 2014, no individual health plan may be offered, sold, issued, or
25.4with respect to children age 18 or under renewed, to a Minnesota resident that contains a
25.5preexisting condition limitation, preexisting condition exclusion, or exclusionary rider,
25.6unless the limitation or exclusion is permitted under this subdivision and under chapter
25.762L, provided that, except for children age 18 or under, underwriting restrictions may
25.8be retained on individual contracts that are issued without evidence of insurability as a
25.9replacement for prior individual coverage that was sold before May 17, 1993. The An
25.10 individual age 19 or older may be subjected to an 18-month preexisting condition limitation
25.11 during plan years beginning prior to January 1, 2014, unless the individual has maintained
25.12continuous coverage as defined in section 62L.02. The individual must not be subjected to
25.13an exclusionary rider. During plan years beginning prior to January 1, 2014, an individual
25.14who is age 19 or older and who has maintained continuous coverage may be subjected to a
25.15onetime preexisting condition limitation of up to 12 months, with credit for time covered
25.16under qualifying coverage as defined in section 62L.02, at the time that the individual first
25.17is covered under an individual health plan by any health carrier. Credit must be given for
25.18all qualifying coverage with respect to all preexisting conditions, regardless of whether
25.19the conditions were preexisting with respect to any previous qualifying coverage. The
25.20individual must not be subjected to an exclusionary rider. Thereafter, the individual who is
25.21age 19 or older must not be subject to any preexisting condition limitation, preexisting
25.22condition exclusion, or exclusionary rider under an individual health plan by any health
25.23carrier, except an unexpired portion of a limitation under prior coverage, so long as the
25.24individual maintains continuous coverage as defined in section 62L.02. The prohibition on
25.25preexisting condition limitations for children age 18 or under does not apply to individual
25.26health plans that are grandfathered plans. The prohibition on preexisting condition
25.27limitations for adults age 19 and over beginning for plan years on or after January 1, 2014,
25.28does not apply to individual health plans that are grandfathered plans.
25.29(b) A health carrier must offer an individual health plan to any individual previously
25.30covered under a group health plan issued by that health carrier, regardless of the size of
25.31the group, so long as the individual maintained continuous coverage as defined in section
25.3262L.02 . If the individual has available any continuation coverage provided under sections
25.3362A.146 ; 62A.148; 62A.17, subdivisions 1 and 2; 62A.20; 62A.21; 62C.142; 62D.101; or
25.3462D.105 , or continuation coverage provided under federal law, the health carrier need not
25.35offer coverage under this paragraph until the individual has exhausted the continuation
25.36coverage. The offer must not be subject to underwriting, except as permitted under this
26.1paragraph. A health plan issued under this paragraph must be a qualified plan as defined
26.2in section 62E.02 and must not contain any preexisting condition limitation, preexisting
26.3condition exclusion, or exclusionary rider, except for any unexpired limitation or
26.4exclusion under the previous coverage. The individual health plan must cover pregnancy
26.5on the same basis as any other covered illness under the individual health plan. The offer
26.6of coverage by the health carrier must inform the individual that the coverage, including
26.7what is covered and the health care providers from whom covered care may be obtained,
26.8may not be the same as the individual's coverage under the group health plan. The offer
26.9of coverage by the health carrier must also inform the individual that the individual, if
26.10a Minnesota resident, may be eligible to obtain coverage from (i) other private sources
26.11of health coverage, or (ii) the Minnesota Comprehensive Health Association, without a
26.12preexisting condition limitation, and must provide the telephone number used by that
26.13association for enrollment purposes. The initial premium rate for the individual health
26.14plan must comply with subdivision 3. The premium rate upon renewal must comply with
26.15subdivision 2. In no event shall the premium rate exceed 100 percent of the premium
26.16charged for comparable individual coverage by the Minnesota Comprehensive Health
26.17Association, and the premium rate must be less than that amount if necessary to otherwise
26.18comply with this section. An individual health plan offered under this paragraph to a
26.19person satisfies the health carrier's obligation to offer conversion coverage under section
26.2062E.16, with respect to that person. Coverage issued under this paragraph must provide
26.21that it cannot be canceled or nonrenewed as a result of the health carrier's subsequent
26.22decision to leave the individual, small employer, or other group market. Section 72A.20,
26.23subdivision 28
, applies to this paragraph.
26.24EFFECTIVE DATE.This section is effective the day following final enactment,
26.25except that the amendment to paragraph (b) is effective January 1, 2014.

26.26    Sec. 30. Minnesota Statutes 2012, section 62A.65, subdivision 6, is amended to read:
26.27    Subd. 6. Guaranteed issue not required. (a) Nothing in this section requires a
26.28health carrier to initially issue a health plan to a Minnesota resident who is age 19 or older
26.29on the date the health plan becomes effective if the effective date is prior to January 1,
26.302014, except as otherwise expressly provided in subdivision 4 or 5.
26.31(b) Guaranteed issue is required for all health plans, except grandfathered plans,
26.32beginning January 1, 2014.
26.33EFFECTIVE DATE.This section is effective the day following final enactment.

27.1    Sec. 31. Minnesota Statutes 2012, section 62A.65, subdivision 7, is amended to read:
27.2    Subd. 7. Short-term coverage. (a) For purposes of this section, "short-term
27.3coverage" means an individual health plan that:
27.4(1) is issued to provide coverage for a period of 185 days or less, except that the
27.5health plan may permit coverage to continue until the end of a period of hospitalization
27.6for a condition for which the covered person was hospitalized on the day that coverage
27.7would otherwise have ended;
27.8(2) is nonrenewable, provided that the health carrier may provide coverage for one or
27.9more subsequent periods that satisfy clause (1), if the total of the periods of coverage do not
27.10exceed a total of 365 days out of any 555-day period, plus any additional days covered as a
27.11result of hospitalization on the day that a period of coverage would otherwise have ended;
27.12(3) does not cover any preexisting conditions, including ones that originated during
27.13a previous identical policy or contract with the same health carrier where coverage was
27.14continuous between the previous and the current policy or contract; and
27.15(4) is available with an immediate effective date without underwriting upon receipt
27.16of a completed application indicating eligibility under the health carrier's eligibility
27.17requirements, provided that coverage that includes optional benefits may be offered on a
27.18basis that does not meet this requirement.
27.19(b) Short-term coverage is not subject to subdivisions 2 and 5. Short-term coverage
27.20may exclude as a preexisting condition any injury, illness, or condition for which the
27.21covered person had medical treatment, symptoms, or any manifestations before the
27.22effective date of the coverage, but dependent children born or placed for adoption during
27.23the policy period must not be subject to this provision.
27.24(c) Notwithstanding subdivision 3, and section 62A.021, a health carrier may
27.25combine short-term coverage with its most commonly sold individual qualified plan, as
27.26defined in section 62E.02, other than short-term coverage, for purposes of complying
27.27with the loss ratio requirement.
27.28(d) The 365-day coverage limitation provided in paragraph (a) applies to the total
27.29number of days of short-term coverage that covers a person, regardless of the number of
27.30policies, contracts, or health carriers that provide the coverage. A written application for
27.31short-term coverage must ask the applicant whether the applicant has been covered by
27.32short-term coverage by any health carrier within the 555 days immediately preceding the
27.33effective date of the coverage being applied for. Short-term coverage issued in violation
27.34of the 365-day limitation is valid until the end of its term and does not lose its status as
27.35short-term coverage, in spite of the violation. A health carrier that knowingly issues
27.36short-term coverage in violation of the 365-day limitation is subject to the administrative
28.1penalties otherwise available to the commissioner of commerce or the commissioner
28.2of health, as appropriate.
28.3(e) Time spent under short-term coverage counts as time spent under a preexisting
28.4condition limitation for purposes of group or individual health plans, other than short-term
28.5coverage, subsequently issued to that person, or to cover that person, by any health carrier,
28.6if the person maintains continuous coverage as defined in section 62L.02. Short-term
28.7coverage is a health plan and is qualifying coverage as defined in section 62L.02.
28.8Notwithstanding any other law to the contrary, a health carrier is not required under any
28.9circumstances to provide a person covered by short-term coverage the right to obtain
28.10coverage on a guaranteed issue basis under another health plan offered by the health
28.11carrier, as a result of the person's enrollment in short-term coverage.
28.12EFFECTIVE DATE.This section is effective the day following final enactment.

28.13    Sec. 32. Minnesota Statutes 2012, section 62C.14, subdivision 5, is amended to read:
28.14    Subd. 5. Disabled dependents. A subscriber's individual contract or any group
28.15contract delivered or issued for delivery in this state and providing that coverage of
28.16a dependent child of the subscriber or a dependent child of a covered group member
28.17shall terminate upon attainment of a specified limiting age as defined in section 62Q.01,
28.18subdivision 9, shall also provide in substance that attainment of that age shall not terminate
28.19coverage while the child is (a) incapable of self-sustaining employment by reason of
28.20developmental disability, mental illness or disorder, or physical disability, and (b) chiefly
28.21dependent upon the subscriber or employee for support and maintenance, provided proof
28.22of incapacity and dependency is furnished by the subscriber within 31 days of attainment
28.23of the limiting age as defined in section 62Q.01, subdivision 9, and subsequently as
28.24required by the corporation, but not more frequently than annually after a two-year period
28.25following attainment of the age. Any notice regarding termination of coverage due to
28.26attainment of the limiting age must include information about this provision.
28.27EFFECTIVE DATE.This section is effective the day following final enactment.

28.28    Sec. 33. Minnesota Statutes 2012, section 62C.142, subdivision 2, is amended to read:
28.29    Subd. 2. Conversion privilege. Every subscriber contract, other than a contract
28.30whose continuance is contingent upon continued employment or membership, which
28.31contains a provision for termination of coverage of the spouse upon dissolution of
28.32marriage shall contain a provision allowing a former spouse and dependent children of a
28.33subscriber, without providing evidence of insurability, to obtain from the corporation at
29.1the expiration of any continuation of coverage required under subdivision 2a or section
29.262A.146, or upon termination of coverage by reason of an entry of a valid decree of
29.3dissolution which does not require the insured to provide continued coverage for the
29.4former spouse, an individual subscriber contract providing at least the minimum benefits
29.5of a qualified plan as prescribed by section 62E.06 and the option of a number three
29.6qualified plan, a number two qualified plan, a number one qualified plan as provided by
29.7section 62E.06, subdivisions 1 to 3, provided application is made to the corporation within
29.830 days following notice of the expiration of the continued coverage and upon payment of
29.9the appropriate fee. A subscriber contract providing reduced benefits at a reduced fee may
29.10be accepted by the former spouse and dependent children in lieu of the optional coverage
29.11otherwise required by this subdivision. The An individual subscriber contract issued as
29.12conversion coverage shall be renewable at the option of the former spouse as long as the
29.13former spouse is not covered under another qualified plan as defined in section 62E.02,
29.14subdivision 4
. Any revisions in the table of rate for the individual subscriber contract shall
29.15apply to the former spouse's original age at entry and shall apply equally to all similar
29.16contracts issued as conversion coverage by the corporation.
29.17EFFECTIVE DATE.This section is effective January 1, 2014.

29.18    Sec. 34. Minnesota Statutes 2012, section 62D.07, subdivision 3, is amended to read:
29.19    Subd. 3. Required provisions. Contracts and evidences of coverage shall contain:
29.20(a) no provisions or statements which are unjust, unfair, inequitable, misleading,
29.21deceptive, or which are untrue, misleading, or deceptive as defined in section 62D.12,
29.22subdivision 1
;
29.23(b) a clear, concise and complete statement of:
29.24(1) the health care services and the insurance or other benefits, if any, to which the
29.25enrollee is entitled under the health maintenance contract;
29.26(2) any exclusions or limitations on the services, kind of services, benefits, or kind of
29.27benefits, to be provided, including any deductible or co-payment feature and requirements
29.28for referrals, prior authorizations, and second opinions;
29.29(3) where and in what manner information is available as to how services, including
29.30emergency and out of area services, may be obtained;
29.31(4) the total amount of payment and co-payment, if any, for health care services
29.32and the indemnity or service benefits, if any, which the enrollee is obligated to pay
29.33with respect to individual contracts, or an indication whether the plan is contributory or
29.34noncontributory with respect to group certificates; and
30.1(5) a description of the health maintenance organization's method for resolving
30.2enrollee complaints and a statement identifying the commissioner as an external source
30.3with whom complaints may be registered; and
30.4(c) on the cover page of the evidence of coverage and contract, a clear and complete
30.5statement of enrollees' rights. The statement must be in bold print and captioned
30.6"Important Enrollee Information and Enrollee Bill of Rights" and must include but not be
30.7limited to the following provisions in the following language or in substantially similar
30.8language approved in advance by the commissioner, except that paragraph (8) does not
30.9apply to prepaid health plans providing coverage for programs administered by the
30.10commissioner of human services:
30.11ENROLLEE INFORMATION
30.12(1) COVERED SERVICES: Services provided by (name of health maintenance
30.13organization) will be covered only if services are provided by participating (name of
30.14health maintenance organization) providers or authorized by (name of health maintenance
30.15organization). Your contract fully defines what services are covered and describes
30.16procedures you must follow to obtain coverage.
30.17(2) PROVIDERS: Enrolling in (name of health maintenance organization) does not
30.18guarantee services by a particular provider on the list of providers. When a provider is
30.19no longer part of (name of health maintenance organization), you must choose among
30.20remaining (name of the health maintenance organization) providers.
30.21(3) REFERRALS: Certain services are covered only upon referral. See section
30.22(section number) of your contract for referral requirements. All referrals to non-(name of
30.23health maintenance organization) providers and certain types of health care providers must
30.24be authorized by (name of health maintenance organization).
30.25(4) EMERGENCY SERVICES: Emergency services from providers who are not
30.26affiliated with (name of health maintenance organization) will be covered only if proper
30.27procedures are followed. Your contract explains the procedures and benefits associated
30.28with emergency care from (name of health maintenance organization) and non-(name of
30.29health maintenance organization) providers.
30.30(5) EXCLUSIONS: Certain services or medical supplies are not covered. You
30.31should read the contract for a detailed explanation of all exclusions.
30.32(6) CONTINUATION: You may convert to an individual health maintenance
30.33organization contract or continue coverage under certain circumstances. These
30.34continuation and conversion rights are explained fully in your contract.
31.1(7) CANCELLATION: Your coverage may be canceled by you or (name of health
31.2maintenance organization) only under certain conditions. Your contract describes all
31.3reasons for cancellation of coverage.
31.4(8) NEWBORN COVERAGE: If your health plan provides for dependent coverage,
31.5a newborn infant is covered from birth, but only if services are provided by participating
31.6(name of health maintenance organization) providers or authorized by (name of health
31.7maintenance organization). Certain services are covered only upon referral. (Name
31.8of health maintenance organization) will not automatically know of the infant's birth
31.9or that you would like coverage under your plan. You should notify (name of health
31.10maintenance organization) of the infant's birth and that you would like coverage. If your
31.11contract requires an additional premium for each dependent, (name of health maintenance
31.12organization) is entitled to all premiums due from the time of the infant's birth until the
31.13time you notify (name of health maintenance organization) of the birth. (Name of health
31.14maintenance organization) may withhold payment of any health benefits for the newborn
31.15infant until any premiums you owe are paid.
31.16(9) PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT: Enrolling in (name
31.17of health maintenance organization) does not guarantee that any particular prescription
31.18drug will be available nor that any particular piece of medical equipment will be available,
31.19even if the drug or equipment is available at the start of the contract year.
31.20ENROLLEE BILL OF RIGHTS
31.21(1) Enrollees have the right to available and accessible services including emergency
31.22services, as defined in your contract, 24 hours a day and seven days a week;
31.23(2) Enrollees have the right to be informed of health problems, and to receive
31.24information regarding treatment alternatives and risks which is sufficient to assure
31.25informed choice;
31.26(3) Enrollees have the right to refuse treatment, and the right to privacy of medical
31.27and financial records maintained by the health maintenance organization and its health
31.28care providers, in accordance with existing law;
31.29(4) Enrollees have the right to file a complaint with the health maintenance
31.30organization and the commissioner of health and the right to initiate a legal proceeding
31.31when experiencing a problem with the health maintenance organization or its health
31.32care providers;
31.33(5) Enrollees have the right to a grace period of 31 days for the payment of each
31.34premium for an individual health maintenance contract falling due after the first premium
31.35during which period the contract shall continue in force;
32.1(6) Medicare enrollees have the right to voluntarily disenroll from the health
32.2maintenance organization and the right not to be requested or encouraged to disenroll
32.3except in circumstances specified in federal law; and
32.4(7) Medicare enrollees have the right to a clear description of nursing home and
32.5home care benefits covered by the health maintenance organization.
32.6EFFECTIVE DATE.This section is effective the day following final enactment.

32.7    Sec. 35. Minnesota Statutes 2012, section 62D.095, is amended to read:
32.862D.095 ENROLLEE COST SHARING.
32.9    Subdivision 1. General application. A health maintenance contract may contain
32.10enrollee cost-sharing provisions as specified in this section. Co-payment and deductible
32.11provisions in a group contract must not discriminate on the basis of age, sex, race,
32.12disability, economic status, or length of enrollment in the health plan. During an
32.13open enrollment period in which all offered health plans fully participate without any
32.14underwriting restrictions, co-payment and deductible provisions must not discriminate
32.15on the basis of preexisting health status.
32.16    Subd. 2. Co-payments. (a) A health maintenance contract may impose a
32.17co-payment as authorized under Minnesota Rules, part 4685.0801, or under this section
32.18 and coinsurance consistent with the provisions of the Affordable Care Act as defined
32.19under section 62A.011, subdivision 1a.
32.20(b) A health maintenance organization may impose a flat fee co-payment on
32.21outpatient office visits not to exceed 40 percent of the median provider's charges for
32.22similar services or goods received by the enrollees as calculated under Minnesota Rules,
32.23part 4685.0801. A health maintenance organization may impose a flat fee co-payment on
32.24outpatient prescription drugs not to exceed 50 percent of the median provider's charges
32.25for similar services or goods received by the enrollees as calculated under Minnesota
32.26Rules, part 4685.0801.
32.27(c) If a health maintenance contract is permitted to impose a co-payment for
32.28preexisting health status under sections 62D.01 to 62D.30, these provisions may vary with
32.29respect to length of enrollment in the health plan.
32.30    Subd. 3. Deductibles. (a) A health maintenance contract issued by a health
32.31maintenance organization that is assessed less than three percent of the total annual amount
32.32assessed by the Minnesota comprehensive health association may impose deductibles not
32.33to exceed $3,000 per person, per year and $6,000 per family, per year. For purposes of
32.34the percentage calculation, a health maintenance organization's assessments include those
33.1of its affiliates may impose a deductible consistent with the provisions of the Affordable
33.2Care Act as defined under section 62A.011, subdivision 1a.
33.3(b) All other health maintenance contracts may impose deductibles not to exceed
33.4$2,250 per person, per year and $4,500 per family, per year.
33.5    Subd. 4. Annual out-of-pocket maximums. (a) A health maintenance contract
33.6issued by a health maintenance organization that is assessed less than three percent of the
33.7total annual amount assessed by the Minnesota comprehensive health association must
33.8include a limitation not to exceed $4,500 per person and $7,500 per family on total annual
33.9out-of-pocket enrollee cost-sharing expenses. For purposes of the percentage calculation,
33.10a health maintenance organization's assessments include those of its affiliates may impose
33.11an annual out-of-pocket maximum consistent with the provisions of the Affordable Care
33.12Act as defined under section 62A.011, subdivision 1a.
33.13(b) All other health maintenance contracts must include a limitation not to
33.14exceed $3,000 per person and $6,000 per family on total annual out-of-pocket enrollee
33.15cost-sharing expenses.
33.16    Subd. 5. Exceptions. No co-payments or deductibles may be imposed on preventive
33.17health care services as described in Minnesota Rules, part 4685.0801, subpart 8 consistent
33.18with the provisions of the Affordable Care Act as defined under section 62A.011,
33.19subdivision 1a.
33.20    Subd. 6. Public programs. This section does not apply to the prepaid medical
33.21assistance program, the MinnesotaCare program, the prepaid general assistance program,
33.22the federal Medicare program, or the health plans provided through any of those programs.
33.23EFFECTIVE DATE.This section is effective January 1, 2014.

33.24    Sec. 36. Minnesota Statutes 2012, section 62D.181, subdivision 7, is amended to read:
33.25    Subd. 7. Replacement coverage; limitations. The association is not obligated
33.26to offer replacement coverage under this chapter or conversion coverage under section
33.2762E.16 at the end of the periods specified in subdivision 6. Any continuation obligation
33.28arising under this chapter or chapter 62A will cease at the end of the periods specified in
33.29subdivision 6.
33.30EFFECTIVE DATE.This section is effective January 1, 2014.

33.31    Sec. 37. Minnesota Statutes 2012, section 62E.02, is amended by adding a subdivision
33.32to read:
34.1    Subd. 2a. Essential health benefits. "Essential health benefits" has the meaning
34.2given under section 62Q.81, subdivision 4.
34.3EFFECTIVE DATE.This section is effective January 1, 2014.

34.4    Sec. 38. Minnesota Statutes 2012, section 62E.04, subdivision 4, is amended to read:
34.5    Subd. 4. Major medical coverage. Each insurer and fraternal shall affirmatively
34.6offer coverage of major medical expenses to every applicant who applies to the insurer
34.7or fraternal for a new unqualified policy, which has a lifetime benefit limit of less than
34.8$1,000,000, at the time of application and annually to every holder of such an unqualified
34.9policy of accident and health insurance renewed by the insurer or fraternal. The coverage
34.10shall provide that when a covered individual incurs out-of-pocket expenses of $5,000
34.11or more within a calendar year for services covered in section 62E.06, subdivision 1,
34.12benefits shall be payable, subject to any co-payment authorized by the commissioner, up
34.13to a maximum lifetime limit of not less than $1,000,000 and shall not contain a lifetime
34.14maximum on essential health benefits. The offer of coverage of major medical expenses
34.15may consist of the offer of a rider on an existing unqualified policy or a new policy which
34.16is a qualified plan.
34.17EFFECTIVE DATE.This section is effective the day following final enactment.

34.18    Sec. 39. Minnesota Statutes 2012, section 62E.04, is amended by adding a subdivision
34.19to read:
34.20    Subd. 11. Essential health benefits package. For individual or small group health
34.21plans that include the essential health benefits package and are offered, sold, issued, or
34.22renewed on or after January 1, 2014, the requirements of this section do not apply.

34.23    Sec. 40. Minnesota Statutes 2012, section 62E.06, subdivision 1, is amended to read:
34.24    Subdivision 1. Number three plan. A plan of health coverage shall be certified as a
34.25number three qualified plan if it otherwise meets the requirements established by chapters
34.2662A, 62C, and 62Q, and the other laws of this state, whether or not the policy is issued in
34.27Minnesota, and meets or exceeds the following minimum standards:
34.28(a) The minimum benefits for a covered individual shall, subject to the other
34.29provisions of this subdivision, be equal to at least 80 percent of the cost of covered services
34.30in excess of an annual deductible which does not exceed $150 per person. The coverage
34.31shall include a limitation of $3,000 per person on total annual out-of-pocket expenses for
35.1services covered under this subdivision. The coverage shall not be subject to a maximum
35.2lifetime benefit of not less than $1,000,000 lifetime maximum on essential health benefits.
35.3The prohibition on lifetime maximums for essential health benefits and $3,000
35.4limitation on total annual out-of-pocket expenses and the $1,000,000 maximum lifetime
35.5benefit shall not be subject to change or substitution by use of an actuarially equivalent
35.6benefit.
35.7(b) Covered expenses shall be the usual and customary charges for the following
35.8services and articles when prescribed by a physician:
35.9(1) hospital services;
35.10(2) professional services for the diagnosis or treatment of injuries, illnesses, or
35.11conditions, other than dental, which are rendered by a physician or at the physician's
35.12direction;
35.13(3) drugs requiring a physician's prescription;
35.14(4) services of a nursing home for not more than 120 days in a year if the services
35.15would qualify as reimbursable services under Medicare;
35.16(5) services of a home health agency if the services would qualify as reimbursable
35.17services under Medicare;
35.18(6) use of radium or other radioactive materials;
35.19(7) oxygen;
35.20(8) anesthetics;
35.21(9) prostheses other than dental but including scalp hair prostheses worn for hair
35.22loss suffered as a result of alopecia areata;
35.23(10) rental or purchase, as appropriate, of durable medical equipment other than
35.24eyeglasses and hearing aids, unless coverage is required under section 62Q.675;
35.25(11) diagnostic x-rays and laboratory tests;
35.26(12) oral surgery for partially or completely unerupted impacted teeth, a tooth root
35.27without the extraction of the entire tooth, or the gums and tissues of the mouth when not
35.28performed in connection with the extraction or repair of teeth;
35.29(13) services of a physical therapist;
35.30(14) transportation provided by licensed ambulance service to the nearest facility
35.31qualified to treat the condition; or a reasonable mileage rate for transportation to a kidney
35.32dialysis center for treatment; and
35.33(15) services of an occupational therapist.
35.34(c) Covered expenses for the services and articles specified in this subdivision do
35.35not include the following:
36.1(1) any charge for care for injury or disease either (i) arising out of an injury in the
36.2course of employment and subject to a workers' compensation or similar law, (ii) for
36.3which benefits are payable without regard to fault under coverage statutorily required
36.4to be contained in any motor vehicle, or other liability insurance policy or equivalent
36.5self-insurance, or (iii) for which benefits are payable under another policy of accident and
36.6health insurance, Medicare, or any other governmental program except as otherwise
36.7provided by section 62A.04, subdivision 3, clause (4);
36.8(2) any charge for treatment for cosmetic purposes other than for reconstructive
36.9surgery when such service is incidental to or follows surgery resulting from injury,
36.10sickness, or other diseases of the involved part or when such service is performed on a
36.11covered dependent child because of congenital disease or anomaly which has resulted in a
36.12functional defect as determined by the attending physician;
36.13(3) care which is primarily for custodial or domiciliary purposes which would not
36.14qualify as eligible services under Medicare;
36.15(4) any charge for confinement in a private room to the extent it is in excess of
36.16the institution's charge for its most common semiprivate room, unless a private room is
36.17prescribed as medically necessary by a physician, provided, however, that if the institution
36.18does not have semiprivate rooms, its most common semiprivate room charge shall be
36.19considered to be 90 percent of its lowest private room charge;
36.20(5) that part of any charge for services or articles rendered or prescribed by a
36.21physician, dentist, or other health care personnel which exceeds the prevailing charge in
36.22the locality where the service is provided; and
36.23(6) any charge for services or articles the provision of which is not within the scope
36.24of authorized practice of the institution or individual rendering the services or articles.
36.25(d) The minimum benefits for a qualified plan shall include, in addition to those
36.26benefits specified in clauses (a) and (e), benefits for well baby care, effective July 1,
36.271980, subject to applicable deductibles, coinsurance provisions, and maximum lifetime
36.28benefit limitations.
36.29(e) Effective July 1, 1979, the minimum benefits of a qualified plan shall include, in
36.30addition to those benefits specified in clause (a), a second opinion from a physician on
36.31all surgical procedures expected to cost a total of $500 or more in physician, laboratory,
36.32and hospital fees, provided that the coverage need not include the repetition of any
36.33diagnostic tests.
36.34(f) Effective August 1, 1985, the minimum benefits of a qualified plan must include,
36.35in addition to the benefits specified in clauses (a), (d), and (e), coverage for special dietary
36.36treatment for phenylketonuria when recommended by a physician.
37.1(g) Outpatient mental health coverage is subject to section 62A.152, subdivision 2.
37.2EFFECTIVE DATE.This section is effective the day following final enactment.

37.3    Sec. 41. Minnesota Statutes 2012, section 62E.09, is amended to read:
37.462E.09 DUTIES OF COMMISSIONER.
37.5The commissioner may:
37.6(a) formulate general policies to advance the purposes of sections 62E.01 to 62E.19;
37.7(b) supervise the creation of the Minnesota Comprehensive Health Association
37.8within the limits described in section 62E.10;
37.9(c) approve the selection of the writing carrier by the association, approve the
37.10association's contract with the writing carrier, and approve the state plan coverage;
37.11(d) appoint advisory committees;
37.12(e) conduct periodic audits to assure the general accuracy of the financial data
37.13submitted by the writing carrier and the association;
37.14(f) contract with the federal government or any other unit of government to ensure
37.15coordination of the state plan with other governmental assistance programs;
37.16(g) undertake directly or through contracts with other persons studies or
37.17demonstration programs to develop awareness of the benefits of sections 62E.01 to 62E.16
37.18
62E.15, so that the residents of this state may best avail themselves of the health care
37.19benefits provided by these sections;
37.20(h) contract with insurers and others for administrative services; and
37.21(i) adopt, amend, suspend and repeal rules as reasonably necessary to carry out and
37.22make effective the provisions and purposes of sections 62E.01 to 62E.19.
37.23EFFECTIVE DATE.This section is effective January 1, 2014.

37.24    Sec. 42. Minnesota Statutes 2012, section 62E.10, subdivision 7, is amended to read:
37.25    Subd. 7. General powers. The association may:
37.26(a) Exercise the powers granted to insurers under the laws of this state;
37.27(b) Sue or be sued;
37.28(c) Enter into contracts with insurers, similar associations in other states or with
37.29other persons for the performance of administrative functions including the functions
37.30provided for in clauses (e) and (f);
37.31(d) Establish administrative and accounting procedures for the operation of the
37.32association;
38.1(e) Provide for the reinsuring of risks incurred as a result of issuing the coverages
38.2required by sections section 62E.04 and 62E.16 by members of the association. Each
38.3member which elects to reinsure its required risks shall determine the categories of
38.4coverage it elects to reinsure in the association. The categories of coverage are:
38.5(1) individual qualified plans, excluding group conversions;
38.6(2) group conversions;
38.7(3) group qualified plans with fewer than 50 employees or members; and
38.8(4) major medical coverage.
38.9A separate election may be made for each category of coverage. If a member elects
38.10to reinsure the risks of a category of coverage, it must reinsure the risk of the coverage
38.11of every life covered under every policy issued in that category. A member electing to
38.12reinsure risks of a category of coverage shall enter into a contract with the association
38.13establishing a reinsurance plan for the risks. This contract may include provision for
38.14the pooling of members' risks reinsured through the association and it may provide for
38.15assessment of each member reinsuring risks for losses and operating and administrative
38.16expenses incurred, or estimated to be incurred in the operation of the reinsurance plan. This
38.17reinsurance plan shall be approved by the commissioner before it is effective. Members
38.18electing to administer the risks which are reinsured in the association shall comply with the
38.19benefit determination guidelines and accounting procedures established by the association.
38.20The fee charged by the association for the reinsurance of risks shall not be less than 110
38.21percent of the total anticipated expenses incurred by the association for the reinsurance; and
38.22(f) Provide for the administration by the association of policies which are reinsured
38.23pursuant to clause (e). Each member electing to reinsure one or more categories of
38.24coverage in the association may elect to have the association administer the categories of
38.25coverage on the member's behalf. If a member elects to have the association administer
38.26the categories of coverage, it must do so for every life covered under every policy issued
38.27in that category. The fee for the administration shall not be less than 110 percent of the
38.28total anticipated expenses incurred by the association for the administration.
38.29EFFECTIVE DATE.This section is effective January 1, 2014.

38.30    Sec. 43. Minnesota Statutes 2012, section 62H.04, is amended to read:
38.3162H.04 COMPLIANCE WITH OTHER LAWS.
38.32(a) A joint self-insurance plan is subject to the requirements of chapters 62A, 62E,
38.3362L, and 62Q, and sections 72A.17 to 72A.32 unless otherwise specifically exempt. A
39.1joint self-insurance plan must pay assessments made by the Minnesota Comprehensive
39.2Health Association, as required under section 62E.11.
39.3(b) A joint self-insurance plan is exempt from providing the mandated health
39.4benefits described in chapters 62A, 62E, 62L, and 62Q if it otherwise provides the benefits
39.5required under the Employee Retirement Income Security Act of 1974, United States
39.6Code, title 29, sections 1001, et seq., for all employers and not just for the employers with
39.750 or more employees who are covered by that federal law.
39.8(c) A joint self-insurance plan is exempt from section 62L.03, subdivision 1, if the
39.9plan offers an annual open enrollment period of no less than 15 days during which all
39.10employers that qualify for membership may enter the plan without preexisting condition
39.11limitations or exclusions except those permitted under chapter 62L.
39.12(d) A joint self-insurance plan is exempt from sections 62A.146, 62A.16, 62A.17,
39.1362A.20 , 62A.21, and 62A.65, subdivision 5, paragraph (b), and 62E.16 if the joint
39.14self-insurance plan complies with the continuation requirements under the Employee
39.15Retirement Income Security Act of 1974, United States Code, title 29, sections 1001, et
39.16seq., for all employers and not just for the employers with 20 or more employees who
39.17are covered by that federal law.
39.18(e) A joint self-insurance plan must provide to all employers the maternity coverage
39.19required by federal law for employers with 15 or more employees.
39.20(f) A joint self-insurance plan must comply with all the provisions and requirements
39.21of the Affordable Care Act as defined under section 62A.011, subdivision 1a, to the extent
39.22that they apply to such plans.
39.23EFFECTIVE DATE.This section is effective the day following final enactment,
39.24except that the amendment to paragraph (d) is effective January 1, 2014.

39.25    Sec. 44. Minnesota Statutes 2012, section 62L.02, subdivision 11, is amended to read:
39.26    Subd. 11. Dependent. "Dependent" means an eligible employee's spouse,
39.27unmarried child who is under the age of 25 years dependent child to the limiting age as
39.28defined in section 62Q.01, subdivision 9, dependent child of any age who is disabled and
39.29who meets the eligibility criteria in section 62A.14, subdivision 2, or any other person
39.30whom state or federal law requires to be treated as a dependent for purposes of health
39.31plans. For the purpose of this definition, a dependent child to the limiting age as defined in
39.32section 62Q.01, subdivision 9, includes a child for whom the employee or the employee's
39.33spouse has been appointed legal guardian and an adoptive child as provided in section
39.3462A.27 . A child also means a grandchild as provided in section 62A.042 with continued
39.35eligibility of grandchildren as provided in section 62A.302, subdivision 4.
40.1EFFECTIVE DATE.This section is effective the day following final enactment.

40.2    Sec. 45. Minnesota Statutes 2012, section 62L.02, subdivision 14a, is amended to read:
40.3    Subd. 14a. Guaranteed issue. "Guaranteed issue" means that a health carrier shall
40.4not decline an application by a small employer for any health benefit plan offered by
40.5that health carrier and shall not decline to cover under a health benefit plan any eligible
40.6employee or eligible dependent, including persons who become eligible employees or
40.7eligible dependents after initial issuance of the health benefit plan, subject to the health
40.8carrier's right to impose preexisting condition limitations permitted under this chapter.
40.9EFFECTIVE DATE.This section is effective January 1, 2014.

40.10    Sec. 46. Minnesota Statutes 2012, section 62L.02, is amended by adding a subdivision
40.11to read:
40.12    Subd. 17a. Individual health plan. "Individual health plan" has the meaning
40.13given in section 62A.011, subdivision 4.
40.14EFFECTIVE DATE.This section is effective January 1, 2014.

40.15    Sec. 47. Minnesota Statutes 2012, section 62L.02, subdivision 26, is amended to read:
40.16    Subd. 26. Small employer. (a) "Small employer" means, with respect to a calendar
40.17year and a plan year, a person, firm, corporation, partnership, association, or other entity
40.18actively engaged in business in Minnesota, including a political subdivision of the state, that
40.19employed an average of no fewer than two nor at least one, not including a sole proprietor,
40.20but not more than 50 current employees on business days during the preceding calendar
40.21year and that employs at least two one current employees employee, not including a sole
40.22proprietor, on the first day of the plan year. If an employer has only one eligible employee
40.23who has not waived coverage, the sale of a health plan to or for that eligible employee
40.24is not a sale to a small employer and is not subject to this chapter and may be treated as
40.25the sale of an individual health plan. A small employer plan may be offered through a
40.26domiciled association to self-employed individuals and small employers who are members
40.27of the association, even if the self-employed individual or small employer has fewer than
40.28two current employees. Entities that are treated as a single employer under subsection (b),
40.29(c), (m), or (o) of section 414 of the federal Internal Revenue Code are considered a single
40.30employer for purposes of determining the number of current employees. Small employer
40.31status must be determined on an annual basis as of the renewal date of the health benefit
40.32plan. The provisions of this chapter continue to apply to an employer who no longer meets
41.1the requirements of this definition until the annual renewal date of the employer's health
41.2benefit plan. If an employer was not in existence throughout the preceding calendar year,
41.3the determination of whether the employer is a small employer is based upon the average
41.4number of current employees that it is reasonably expected that the employer will employ
41.5on business days in the current calendar year. For purposes of this definition, the term
41.6employer includes any predecessor of the employer. An employer that has more than 50
41.7current employees but has 50 or fewer employees, as "employee" is defined under United
41.8States Code, title 29, section 1002(6), is a small employer under this subdivision.
41.9(b) Where an association, as defined in section 62L.045, comprised of employers
41.10contracts with a health carrier to provide coverage to its members who are small employers,
41.11the association and health benefit plans it provides to small employers, are subject to
41.12section 62L.045, with respect to small employers in the association, even though the
41.13association also provides coverage to its members that do not qualify as small employers.
41.14(c) If an employer has employees covered under a trust specified in a collective
41.15bargaining agreement under the federal Labor-Management Relations Act of 1947,
41.16United States Code, title 29, section 141, et seq., as amended, or employees whose health
41.17coverage is determined by a collective bargaining agreement and, as a result of the
41.18collective bargaining agreement, is purchased separately from the health plan provided
41.19to other employees, those employees are excluded in determining whether the employer
41.20qualifies as a small employer. Those employees are considered to be a separate small
41.21employer if they constitute a group that would qualify as a small employer in the absence
41.22of the employees who are not subject to the collective bargaining agreement.
41.23(d) Small group health plans offered through the Minnesota Insurance Marketplace
41.24under chapter 62V to employees of a small employer are not considered individual health
41.25plans, regardless of whether the health plan is purchased using a defined contribution
41.26from the small employer.
41.27EFFECTIVE DATE.This section is effective January 1, 2014.

41.28    Sec. 48. Minnesota Statutes 2012, section 62L.03, subdivision 1, is amended to read:
41.29    Subdivision 1. Guaranteed issue and reissue. (a) Every health carrier shall, as a
41.30condition of authority to transact business in this state in the small employer market,
41.31affirmatively market, offer, sell, issue, and renew any of its health benefit plans, on a
41.32guaranteed issue basis, to any small employer, including a small employer covered by
41.33paragraph (b), that meets the participation and contribution requirements of subdivision 3,
41.34as provided in this chapter.
42.1(b) A small employer that has its no longer meets the definition of small employer
42.2because of a reduction in workforce reduced to one employee may continue coverage as a
42.3small employer for 12 months from the date the group is reduced to one employee.
42.4(c) Notwithstanding paragraph (a), a health carrier may, at the time of coverage
42.5renewal, modify the health coverage for a product offered in the small employer market if
42.6the modification is consistent with state law, approved by the commissioner, and effective
42.7on a uniform basis for all small employers purchasing that product other than through a
42.8qualified association in compliance with section 62L.045, subdivision 2.
42.9Paragraph (a) does not apply to a health benefit plan designed for a small employer
42.10to comply with a collective bargaining agreement, provided that the health benefit plan
42.11otherwise complies with this chapter and is not offered to other small employers, except
42.12for other small employers that need it for the same reason. This paragraph applies only
42.13with respect to collective bargaining agreements entered into prior to August 21, 1996,
42.14and only with respect to plan years beginning before the later of July 1, 1997, or the date
42.15upon which the last of the collective bargaining agreements relating to the plan terminates
42.16determined without regard to any extension agreed to after August 21, 1996.
42.17(d) Every health carrier participating in the small employer market shall make
42.18available both of the plans described in section 62L.05 to small employers and shall fully
42.19comply with the underwriting and the rate restrictions specified in this chapter for all
42.20health benefit plans issued to small employers.
42.21(e) (d) A health carrier may cease to transact business in the small employer market
42.22as provided under section 62L.09.
42.23EFFECTIVE DATE.This section is effective January 1, 2014.

42.24    Sec. 49. Minnesota Statutes 2012, section 62L.03, subdivision 3, is amended to read:
42.25    Subd. 3. Minimum participation and contribution. (a) A small employer that has
42.26at least 75 percent of its eligible employees who have not waived coverage participating in
42.27a health benefit plan and that contributes at least 50 percent toward the cost of coverage of
42.28each eligible employee must be guaranteed coverage on a guaranteed issue basis from
42.29any health carrier participating in the small employer market. The participation level
42.30of eligible employees must be determined at the initial offering of coverage and at the
42.31renewal date of coverage. A health carrier must not increase the participation requirements
42.32applicable to a small employer at any time after the small employer has been accepted for
42.33coverage. For the purposes of this subdivision, waiver of coverage includes only waivers
42.34due to: (1) coverage under another group health plan; (2) coverage under Medicare
43.1Parts A and B; or (3) coverage under medical assistance under chapter 256B or general
43.2assistance medical care under chapter 256D.
43.3    (b) If a small employer does not satisfy the contribution or participation requirements
43.4under this subdivision, a health carrier may voluntarily issue or renew individual health
43.5plans, or a health benefit plan which must fully comply with this chapter. A health carrier
43.6that provides a health benefit plan to a small employer that does not meet the contribution
43.7or participation requirements of this subdivision must maintain this information in its files
43.8for audit by the commissioner. A health carrier may not offer an individual health plan,
43.9purchased through an arrangement between the employer and the health carrier, to any
43.10employee unless the health carrier also offers the individual health plan, on a guaranteed
43.11issue basis, to all other employees of the same employer. An arrangement permitted
43.12under section 62L.12, subdivision 2, paragraph (k) (l), is not an arrangement between the
43.13employer and the health carrier for purposes of this paragraph.
43.14    (c) Nothing in this section obligates a health carrier to issue coverage to a small
43.15employer that currently offers coverage through a health benefit plan from another health
43.16carrier, unless the new coverage will replace the existing coverage and not serve as one
43.17of two or more health benefit plans offered by the employer. This paragraph does not
43.18apply if the small employer will meet the required participation level with respect to
43.19the new coverage.
43.20(d) If a small employer cannot meet either the participation or contribution
43.21requirement, the small employer may purchase coverage only during an open enrollment
43.22period each year between November 15 and December 15.
43.23EFFECTIVE DATE.This section is effective January 1, 2014.

43.24    Sec. 50. Minnesota Statutes 2012, section 62L.03, subdivision 4, is amended to read:
43.25    Subd. 4. Underwriting restrictions. (a) Health carriers may apply underwriting
43.26restrictions to coverage for health benefit plans for small employers, including any
43.27preexisting condition limitations, only as expressly permitted under this chapter. For
43.28purposes of this section, "underwriting restrictions" means any refusal of the health carrier
43.29to issue or renew coverage, any premium rate higher than the lowest rate charged by the
43.30health carrier for the same coverage, any preexisting condition limitation, preexisting
43.31condition exclusion, or any exclusionary rider.
43.32(b) Health carriers may collect information relating to the case characteristics and
43.33demographic composition of small employers, as well as health status and health history
43.34information about employees, and dependents of employees, of small employers.
44.1(c) Except as otherwise authorized for late entrants, preexisting conditions may be
44.2excluded by a health carrier for a period not to exceed 12 months from the enrollment
44.3date of an eligible employee or dependent, but exclusionary riders must not be used. Late
44.4entrants may be subject to a preexisting condition limitation not to exceed 18 months from
44.5the enrollment date of the late entrant, but must not be subject to any exclusionary rider or
44.6preexisting condition exclusion. When calculating any length of preexisting condition
44.7limitation, a health carrier shall credit the time period an eligible employee or dependent
44.8was previously covered by qualifying coverage, provided that the individual maintains
44.9continuous coverage. The credit must be given for all qualifying coverage with respect
44.10to all preexisting conditions, regardless of whether the conditions were preexisting with
44.11respect to any previous qualifying coverage. Section 60A.082, relating to replacement of
44.12group coverage, and the rules adopted under that section apply to this chapter, and this
44.13chapter's requirements are in addition to the requirements of that section and the rules
44.14adopted under it. A health carrier shall, at the time of first issuance or renewal of a health
44.15benefit plan on or after July 1, 1993, credit against any preexisting condition limitation
44.16or exclusion permitted under this section, the time period prior to July 1, 1993, during
44.17which an eligible employee or dependent was covered by qualifying coverage, if the
44.18person has maintained continuous coverage.
44.19(d) Health carriers shall not use pregnancy as a preexisting condition under this
44.20chapter.
44.21EFFECTIVE DATE.This section is effective January 1, 2014.

44.22    Sec. 51. Minnesota Statutes 2012, section 62L.03, subdivision 6, is amended to read:
44.23    Subd. 6. MCHA enrollees. Health carriers shall offer coverage to any eligible
44.24employee or dependent enrolled in MCHA at the time of the health carrier's issuance or
44.25renewal of a health benefit plan to a small employer. The health benefit plan must require
44.26that the employer permit MCHA enrollees to enroll in the small employer's health benefit
44.27plan as of the first date of renewal of a health benefit plan occurring on or after July
44.281, 1993, and as of each date of renewal after that, or, in the case of a new group, as of
44.29the initial effective date of the health benefit plan and as of each date of renewal after
44.30that. Unless otherwise permitted by this chapter, Health carriers must not impose any
44.31underwriting restrictions, including any preexisting condition limitations or exclusions, on
44.32any eligible employee or dependent previously enrolled in MCHA and transferred to a
44.33health benefit plan so long as continuous coverage is maintained, provided that the health
44.34carrier may impose any unexpired portion of a preexisting condition limitation under the
45.1person's MCHA coverage. An MCHA enrollee is not a late entrant, so long as the enrollee
45.2has maintained continuous coverage.
45.3EFFECTIVE DATE.This section is effective January 1, 2014.

45.4    Sec. 52. Minnesota Statutes 2012, section 62L.045, subdivision 2, is amended to read:
45.5    Subd. 2. Qualified associations. (a) A qualified association, as defined in this
45.6section, and health coverage offered by it, to it, or through it, to a small employer in
45.7this state must comply with the requirements of this chapter regarding guaranteed issue,
45.8guaranteed renewal, preexisting condition limitations, credit against preexisting condition
45.9limitations for continuous coverage, treatment of MCHA enrollees, and the definition of
45.10dependent, and with section 62A.65, subdivision 5, paragraph (b). They must also comply
45.11with all other requirements of this chapter not specifically exempted in paragraph (b) or (c).
45.12(b) A qualified association and a health carrier offering, selling, issuing, or renewing
45.13health coverage to, or to cover, a small employer in this state through the qualified
45.14association, may, but are not, in connection with that health coverage, required to:
45.15(1) offer the two small employer plans described in section 62L.05; and
45.16(2) offer to small employers that are not members of the association, health coverage
45.17offered to, by, or through the qualified association.
45.18(c) A qualified association, and a health carrier offering, selling, issuing, and
45.19renewing health coverage to, or to cover, a small employer in this state must comply
45.20with section 62L.08, except that:
45.21(1) a separate index rate may be applied by a health carrier to each qualified
45.22association, provided that:
45.23(i) the premium rate applied to participating small employer members of the
45.24qualified association is no more than 25 percent above and no more than 25 percent below
45.25the index rate applied to the qualified association, irrespective of when members applied
45.26for health coverage; and
45.27(ii) the index rate applied by a health carrier to a qualified association is no more
45.28than 20 percent above and no more than 20 percent below the index rate applied by the
45.29health carrier to any other qualified association or to any small employer. In comparing
45.30index rates for purposes of this clause, the 20 percent shall be calculated as a percent of
45.31the larger index rate; and
45.32(2) a qualified association described in subdivision 1, paragraph (a), clauses (2)
45.33to (4), providing health coverage through a health carrier, or on a self-insured basis in
45.34compliance with section 471.617 and the rules adopted under that section, may cover
45.35small employers and other employers within the same pool and may charge premiums
46.1to small employer members on the same basis as it charges premiums to members that
46.2are not small employers, if the premium rates charged to small employers do not have
46.3greater variation than permitted under section 62L.08. A qualified association operating
46.4under this clause shall annually prove to the commissioner of commerce that it complies
46.5with this clause through a sampling procedure acceptable to the commissioner. If the
46.6qualified association fails to prove compliance to the satisfaction of the commissioner,
46.7the association shall agree to a written plan of correction acceptable to the commissioner.
46.8The qualified association is considered to be in compliance under this clause if there is
46.9a premium rate that would, if used as an index rate, result in all premium rates in the
46.10sample being in compliance with section 62L.08. This clause does not exempt a qualified
46.11association or a health carrier providing coverage through the qualified association from
46.12the loss ratio requirement of section 62L.08, subdivision 11.
46.13EFFECTIVE DATE.This section is effective January 1, 2014.

46.14    Sec. 53. Minnesota Statutes 2012, section 62L.045, subdivision 4, is amended to read:
46.15    Subd. 4. Principles; association coverage. (a) This subdivision applies to
46.16associations as defined in this section, whether qualified associations or not, and is
46.17intended to clarify subdivisions 1 to 3.
46.18(b) This section applies only to associations that provide health coverage to small
46.19employers.
46.20(c) A health carrier is not required under this chapter to comply with guaranteed
46.21issue and guaranteed renewal with respect to its relationship with the association itself.
46.22 An arrangement between the health carrier and the association, once entered into, must
46.23comply with guaranteed issue and guaranteed renewal with respect to members of the
46.24association that are small employers and persons covered through them.
46.25(d) When an arrangement between a health carrier and an association has validly
46.26terminated, the health carrier has no continuing obligation to small employers and persons
46.27covered through them, except as otherwise provided in:
46.28(1) section 62A.65, subdivision 5, paragraph (b);
46.29(2) any other continuation or conversion rights applicable under state or federal
46.30law; and
46.31(3) section 60A.082, relating to group replacement coverage, and rules adopted
46.32under that section.
46.33(e) When an association's arrangement with a health carrier has terminated and the
46.34association has entered into a new arrangement with that health carrier or a different
46.35health carrier, the new arrangement is subject to section 60A.082 and rules adopted under
47.1it, with respect to members of the association that are small employers and persons
47.2covered through them.
47.3(f) An association that offers its members more than one plan of health coverage
47.4may have uniform rules restricting movement between the plans of health coverage, if the
47.5rules do not discriminate against small employers.
47.6(g) This chapter does not require or prohibit separation of an association's members
47.7into one group consisting only of small employers and another group or other groups
47.8consisting of all other members. The association must comply with this section with
47.9respect to the small employer group.
47.10(h) For purposes of this section, "member" of an association includes an employer
47.11participant in the association.
47.12(i) For purposes of this section, health coverage issued to, or to cover, a small
47.13employer includes a certificate of coverage issued directly to the employer's employees
47.14and dependents, rather than to the small employer.
47.15EFFECTIVE DATE.This section is effective January 1, 2014.

47.16    Sec. 54. Minnesota Statutes 2012, section 62L.05, subdivision 10, is amended to read:
47.17    Subd. 10. Medical expense reimbursement. Health carriers may reimburse
47.18or pay for medical services, supplies, or articles provided under a small employer plan
47.19in accordance with the health carrier's provider contract requirements including, but
47.20not limited to, salaried arrangements, capitation, the payment of usual and customary
47.21charges, fee schedules, discounts from fee-for-service, per diems, diagnosis-related
47.22groups (DRGs), and other payment arrangements. Nothing in this chapter requires a
47.23health carrier to develop, implement, or change its provider contract requirements for
47.24a small employer plan. Coinsurance, deductibles, and out-of-pocket maximums, and
47.25maximum lifetime benefits must be calculated and determined in accordance with each
47.26health carrier's standard business practices.
47.27EFFECTIVE DATE.This section is effective the day following final enactment.

47.28    Sec. 55. Minnesota Statutes 2012, section 62L.06, is amended to read:
47.2962L.06 DISCLOSURE OF UNDERWRITING RATING PRACTICES.
47.30When offering or renewing a health benefit plan, health carriers shall disclose in all
47.31solicitation and sales materials:
47.32(1) the case characteristics and other rating factors used to determine initial and
47.33renewal rates;
48.1(2) the extent to which premium rates for a small employer are established or
48.2adjusted based upon actual or expected variation in claim experience;
48.3(3) provisions concerning the health carrier's right to change premium rates and the
48.4factors other than claim experience that affect changes in premium rates;
48.5(4) (2) provisions relating to renewability of coverage;
48.6(5) the use and effect of any preexisting condition provisions, if permitted;
48.7(6) (3) the application of any provider network limitations and their effect on
48.8eligibility for benefits; and
48.9(7) (4) the ability of small employers to insure eligible employees and dependents
48.10currently receiving coverage from the Comprehensive Health Association through health
48.11benefit plans.
48.12EFFECTIVE DATE.This section is effective January 1, 2014.

48.13    Sec. 56. Minnesota Statutes 2012, section 62L.08, is amended to read:
48.1462L.08 RESTRICTIONS RELATING TO PREMIUM RATES.
48.15    Subdivision 1. Rate restrictions. Premium rates for all health benefit plans sold or
48.16issued to small employers are subject to the restrictions specified in this section.
48.17    Subd. 2. General premium variations. Beginning July 1, 1993, each health carrier
48.18must offer premium rates to small employers that are no more than 25 percent above
48.19and no more than 25 percent below the index rate charged to small employers for the
48.20same or similar coverage, adjusted pro rata for rating periods of less than one year. The
48.21premium variations permitted by this subdivision must be based only on health status,
48.22claims experience, industry of the employer, and duration of coverage from the date of
48.23issue. For purposes of this subdivision, health status includes refraining from tobacco use
48.24or other actuarially valid lifestyle factors associated with good health, provided that the
48.25lifestyle factor and its effect upon premium rates have been determined to be actuarially
48.26valid and approved by the commissioner. Variations permitted under this subdivision must
48.27not be based upon age or applied differently at different ages. This subdivision does not
48.28prohibit use of a constant percentage adjustment for factors permitted to be used under
48.29this subdivision.
48.30    Subd. 2a. Renewal premium increases limited. (a) Beginning January 1, 2003,
48.31the percentage increase in the premium rate charged to a small employer for a new rating
48.32period must not exceed the sum of the following:
48.33(1) the percentage change in the index rate measured from the first day of the prior
48.34rating period to the first day of the new rating period;
49.1(2) an adjustment, not to exceed 15 percent annually and adjusted pro rata for rating
49.2periods of less than one year, due to the claims experience, health status, or duration of
49.3coverage of the employees or dependents of the employer; and
49.4(3) any adjustment due to change in coverage or in the case characteristics of the
49.5employer.
49.6(b) This subdivision does not apply if the employer, employee, or any applicant
49.7provides the health carrier with false, incomplete, or misleading information.
49.8    Subd. 3. Age-based premium variations. Beginning July 1, 1993, Each health
49.9carrier may offer premium rates to small employers that vary based upon the ages of
49.10the eligible employees and dependents of the small employer only as provided in this
49.11subdivision. In addition to the variation permitted by subdivision 2, each health carrier
49.12may use an additional premium variation based upon age of up to plus or minus 50 percent
49.13of the index rate. Premium rates may vary based upon the ages of the eligible employees
49.14and dependents of the small employer in accordance with the provisions of the Affordable
49.15Care Act as defined in section 62A.011, subdivision 1a.
49.16    Subd. 4. Geographic premium variations. A health carrier may request approval
49.17by the commissioner to establish separate geographic regions determined by the health
49.18carrier and to establish separate index rates for each such region Premium rates may vary
49.19based on geographic rating areas set by the commissioner. The commissioner shall grant
49.20approval if the following conditions are met:
49.21(1) the geographic regions must be applied uniformly by the health carrier;
49.22(2) each geographic region must be composed of no fewer than seven counties that
49.23create a contiguous region; and
49.24(3) the health carrier provides actuarial justification acceptable to the commissioner
49.25for the proposed geographic variations in index rates, establishing that the variations are
49.26based upon differences in the cost to the health carrier of providing coverage.
49.27    Subd. 5. Gender-based rates prohibited. Beginning July 1, 1993, No health carrier
49.28may determine premium rates through a method that is in any way based upon the gender
49.29of eligible employees or dependents. Rates must not in any way reflect marital status or
49.30generalized differences in expected costs between employees and spouses.
49.31    Subd. 6. Rate cells permitted Tobacco rating. Health carriers may use rate cells
49.32and must file with the commissioner the rate cells they use. Rate cells must be based on
49.33the number of adults and children covered under the policy and may reflect the availability
49.34of Medicare coverage. The rates for different rate cells must not in any way reflect marital
49.35status or differences in expected costs between employees and spouses Premium rates
50.1may vary based upon tobacco use in accordance with the provisions of the Affordable
50.2Care Act as defined in section 62A.011, subdivision 1a.
50.3    Subd. 7. Index and Premium rate development. (a) In developing its index rates
50.4and premiums, a health carrier may take into account only the following factors:
50.5(1) actuarially valid differences in benefit designs of health benefit plans; and
50.6(2) actuarially valid differences in the rating factors permitted in subdivisions 2 and 3;
50.7(3) (2) actuarially valid geographic variations if approved by the commissioner as
50.8provided in subdivision 4.
50.9(b) All premium variations permitted under this section must be based upon
50.10actuarially valid differences in expected cost to the health carrier of providing coverage.
50.11The variation must be justified in initial rate filings and upon request of the commissioner in
50.12rate revision filings. All premium variations are subject to approval by the commissioner.
50.13    Subd. 8. Filing requirement. A health carrier that offers, sells, issues, or renews a
50.14health benefit plan for small employers shall file with the commissioner the index rates and
50.15must demonstrate that all rates shall be within the rating restrictions defined in this chapter.
50.16Such demonstration must include the allowable range of rates from the index rates and a
50.17description of how the health carrier intends to use demographic factors including case
50.18characteristics in calculating the premium rates. The rates shall not be approved, unless the
50.19commissioner has determined that the rates are reasonable. In determining reasonableness,
50.20the commissioner shall consider the growth rates applied under section 62J.04, subdivision
50.211
, paragraph (b), to the calendar year or years that the proposed premium rate would be in
50.22effect, and actuarially valid changes in risk associated with the enrollee population, and
50.23actuarially valid changes as a result of statutory changes in Laws 1992, chapter 549.
50.24    Subd. 9. Effect of assessments. Premium rates must comply with the rating
50.25requirements of this section, notwithstanding the imposition of any assessments or
50.26premiums paid by health carriers as provided under sections 62L.13 to 62L.22.
50.27    Subd. 10. Rating report. Beginning January 1, 1995, and annually thereafter, the
50.28commissioners of health and commerce shall provide a joint report to the legislature
50.29on the effect of the rating restrictions required by this section and the appropriateness
50.30of proceeding with additional rate reform. Each report must include an analysis of the
50.31availability of health care coverage due to the rating reform, the equitable and appropriate
50.32distribution of risk and associated costs, the effect on the self-insurance market, and any
50.33resulting or anticipated change in health plan design and market share and availability of
50.34health carriers.
50.35    Subd. 11. Loss ratio standards. Notwithstanding section 62A.02, subdivision 3,
50.36relating to loss ratios, each policy or contract form used with respect to a health benefit
51.1plan offered, or issued in the small employer market, is subject, beginning July 1, 1993,
51.2to section 62A.021. The commissioner of health has, with respect to carriers under that
51.3commissioner's jurisdiction, all of the powers of the commissioner of commerce under
51.4that section.
51.5EFFECTIVE DATE.This section is effective January 1, 2014.

51.6    Sec. 57. Minnesota Statutes 2012, section 62L.12, subdivision 2, is amended to read:
51.7    Subd. 2. Exceptions. (a) A health carrier may sell, issue, or renew individual
51.8conversion policies to eligible employees otherwise eligible for conversion coverage under
51.9section 62D.104 as a result of leaving a health maintenance organization's service area.
51.10(b) A health carrier may sell, issue, or renew individual conversion policies to
51.11eligible employees otherwise eligible for conversion coverage as a result of the expiration
51.12of any continuation of group coverage required under sections 62A.146, 62A.17, 62A.21,
51.1362C.142 , 62D.101, and 62D.105.
51.14(c) A health carrier may sell, issue, or renew conversion policies under section
51.1562E.16 to eligible employees.
51.16(d) A health carrier may sell, issue, or renew individual continuation policies to
51.17eligible employees as required.
51.18(e) A health carrier may sell, issue, or renew individual health plans if the coverage
51.19is appropriate due to an unexpired preexisting condition limitation or exclusion applicable
51.20to the person under the employer's group health plan or due to the person's need for health
51.21care services not covered under the employer's group health plan.
51.22(f) A health carrier may sell, issue, or renew an individual health plan, if the
51.23individual has elected to buy the individual health plan not as part of a general plan to
51.24substitute individual health plans for a group health plan nor as a result of any violation of
51.25subdivision 3 or 4.
51.26(g) A health carrier may sell, issue, or renew an individual health plan if coverage
51.27provided by the employer is determined to be unaffordable under the provisions of the
51.28Affordable Care Act as defined in section 62A.011, subdivision 1a.
51.29(h) Nothing in this subdivision relieves a health carrier of any obligation to provide
51.30continuation or conversion coverage otherwise required under federal or state law.
51.31(h) (i) Nothing in this chapter restricts the offer, sale, issuance, or renewal of
51.32coverage issued as a supplement to Medicare under sections 62A.3099 to 62A.44, or
51.33policies or contracts that supplement Medicare issued by health maintenance organizations,
51.34or those contracts governed by sections 1833, 1851 to 1859, 1860D, or 1876 of the federal
51.35Social Security Act, United States Code, title 42, section 1395 et seq., as amended.
52.1(i) (j) Nothing in this chapter restricts the offer, sale, issuance, or renewal of
52.2individual health plans necessary to comply with a court order.
52.3(j) (k) A health carrier may offer, issue, sell, or renew an individual health plan to
52.4persons eligible for an employer group health plan, if the individual health plan is a high
52.5deductible health plan for use in connection with an existing health savings account, in
52.6compliance with the Internal Revenue Code, section 223. In that situation, the same or
52.7a different health carrier may offer, issue, sell, or renew a group health plan to cover
52.8the other eligible employees in the group.
52.9(k) (l) A health carrier may offer, sell, issue, or renew an individual health plan to
52.10one or more employees of a small employer if the individual health plan is marketed
52.11directly to all employees of the small employer and the small employer does not contribute
52.12directly or indirectly to the premiums or facilitate the administration of the individual
52.13health plan. The requirement to market an individual health plan to all employees does not
52.14require the health carrier to offer or issue an individual health plan to any employee. For
52.15purposes of this paragraph, an employer is not contributing to the premiums or facilitating
52.16the administration of the individual health plan if the employer does not contribute to the
52.17premium and merely collects the premiums from an employee's wages or salary through
52.18payroll deductions and submits payment for the premiums of one or more employees in a
52.19lump sum to the health carrier. Except for coverage under section 62A.65, subdivision 5,
52.20paragraph (b), or 62E.16, at the request of an employee, the health carrier may bill the
52.21employer for the premiums payable by the employee, provided that the employer is not
52.22liable for payment except from payroll deductions for that purpose. If an employer is
52.23submitting payments under this paragraph, the health carrier shall provide a cancellation
52.24notice directly to the primary insured at least ten days prior to termination of coverage for
52.25nonpayment of premium. Individual coverage under this paragraph may be offered only
52.26if the small employer has not provided coverage under section 62L.03 to the employees
52.27within the past 12 months.
52.28The employer must provide a written and signed statement to the health carrier that
52.29the employer is not contributing directly or indirectly to the employee's premiums. The
52.30health carrier may rely on the employer's statement and is not required to guarantee-issue
52.31individual health plans to the employer's other current or future employees.
52.32EFFECTIVE DATE.This section is effective January 1, 2014.

52.33    Sec. 58. Minnesota Statutes 2012, section 62M.05, subdivision 3a, is amended to read:
52.34    Subd. 3a. Standard review determination. (a) Notwithstanding subdivision 3b, an
52.35initial determination on all requests for utilization review must be communicated to the
53.1provider and enrollee in accordance with this subdivision within ten business days of the
53.2request, provided that all information reasonably necessary to make a determination on the
53.3request has been made available to the utilization review organization.
53.4(b) When an initial determination is made to certify, notification must be provided
53.5promptly by telephone to the provider. The utilization review organization shall send
53.6written notification to the provider or shall maintain an audit trail of the determination
53.7and telephone notification. For purposes of this subdivision, "audit trail" includes
53.8documentation of the telephone notification, including the date; the name of the person
53.9spoken to; the enrollee; the service, procedure, or admission certified; and the date of
53.10the service, procedure, or admission. If the utilization review organization indicates
53.11certification by use of a number, the number must be called the "certification number."
53.12For purposes of this subdivision, notification may also be made by facsimile to a verified
53.13number or by electronic mail to a secure electronic mailbox. These electronic forms of
53.14notification satisfy the "audit trail" requirement of this paragraph.
53.15(c) When an initial determination is made not to certify, notification must be
53.16provided by telephone, by facsimile to a verified number, or by electronic mail to a secure
53.17electronic mailbox within one working day after making the determination to the attending
53.18health care professional and hospital as applicable. Written notification must also be sent
53.19to the hospital as applicable and attending health care professional if notification occurred
53.20by telephone. For purposes of this subdivision, notification may be made by facsimile to a
53.21verified number or by electronic mail to a secure electronic mailbox. Written notification
53.22must be sent to the enrollee and may be sent by United States mail, facsimile to a verified
53.23number, or by electronic mail to a secure mailbox. The written notification must include
53.24the principal reason or reasons for the determination and the process for initiating an appeal
53.25of the determination. Upon request, the utilization review organization shall provide the
53.26provider or enrollee with the criteria used to determine the necessity, appropriateness,
53.27and efficacy of the health care service and identify the database, professional treatment
53.28parameter, or other basis for the criteria. Reasons for a determination not to certify may
53.29include, among other things, the lack of adequate information to certify after a reasonable
53.30attempt has been made to contact the provider or enrollee.
53.31(d) When an initial determination is made not to certify, the written notification must
53.32inform the enrollee and the attending health care professional of the right to submit an
53.33appeal to the internal appeal process described in section 62M.06 and the procedure for
53.34initiating the internal appeal. The written notice shall be provided in a culturally and
53.35linguistically appropriate manner consistent with the provisions of the Affordable Care
53.36Act as defined under section 62A.011, subdivision 1a.
54.1EFFECTIVE DATE.This section is effective the day following final enactment.

54.2    Sec. 59. Minnesota Statutes 2012, section 62M.06, subdivision 1, is amended to read:
54.3    Subdivision 1. Procedures for appeal. (a) A utilization review organization must
54.4have written procedures for appeals of determinations not to certify. The right to appeal
54.5must be available to the enrollee and to the attending health care professional.
54.6(b) The enrollee shall be allowed to review the information relied upon in the course
54.7of the appeal, present evidence and testimony as part of the appeals process, and receive
54.8continued coverage pending the outcome of the appeals process. This paragraph does
54.9not apply to managed care plans or county-based purchasing plans serving state public
54.10health care program enrollees under section 256B.69, 256B.692, or chapter 256L, or to
54.11grandfathered plans as defined under section 62A.011, subdivision 1c. Nothing in this
54.12paragraph shall be construed to limit or restrict the appeal rights of state public health care
54.13program enrollees provided under section 256.045 and Code of Federal Regulations, title
54.1442, section 438.420(d).
54.15EFFECTIVE DATE.This section is effective the day following final enactment.

54.16    Sec. 60. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
54.17to read:
54.18    Subd. 1a. Affordable Care Act. "Affordable Care Act" means the Affordable Care
54.19Act as defined in section 62A.011, subdivision 1a.
54.20EFFECTIVE DATE.This section is effective the day following final enactment.

54.21    Sec. 61. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
54.22to read:
54.23    Subd. 1b. Bona fide association. "Bona fide association" means an association that
54.24meets all of the following criteria:
54.25(1) serves a single profession that requires a significant amount of education, training,
54.26or experience, or a license or certificate from a state authority to practice that profession;
54.27(2) has been actively in existence for five years;
54.28(3) has a constitution and bylaws or other analogous governing documents;
54.29(4) has been formed and maintained in good faith for purposes other than obtaining
54.30insurance;
54.31(5) is not owned or controlled by a health plan company or affiliated with a health
54.32plan company;
55.1(6) does not condition membership in the association on any health status-related
55.2factor;
55.3(7) has at least 1,000 members if it is a national association, 500 members if it is a
55.4state association, or 200 members if it is a local association;
55.5(8) all members and dependents of members are eligible for coverage regardless of
55.6any health status-related factor;
55.7(9) does not make health plans offered through the association available other than
55.8in connection with a member of the association;
55.9(10) is governed by a board of directors and sponsors an annual meeting of its
55.10members; and
55.11(11) produces only market association memberships, accepts applications for
55.12membership, or signs up members in the professional association where the subject
55.13individuals are actively engaged in, or directly related to, the profession represented
55.14by the association.
55.15EFFECTIVE DATE.This section is effective the day following final enactment.

55.16    Sec. 62. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
55.17to read:
55.18    Subd. 2b. Grandfathered plan. "Grandfathered plan" means a health plan as
55.19defined in section 62A.011, subdivision 1b.

55.20    Sec. 63. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
55.21to read:
55.22    Subd. 2c. Group health plan. "Group health plan" means a group health plan as
55.23defined in section 62A.011, subdivision 1c.

55.24    Sec. 64. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
55.25to read:
55.26    Subd. 4b. Individual health plan. "Individual health plan" means an individual
55.27health plan as defined in section 62A.011, subdivision 4.

55.28    Sec. 65. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
55.29to read:
55.30    Subd. 7. Life-threatening condition. "Life-threatening condition" means a disease
55.31or condition from which the likelihood of death is probable unless the course of the
55.32disease or condition is interrupted.
56.1EFFECTIVE DATE.This section is effective the day following final enactment.

56.2    Sec. 66. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
56.3to read:
56.4    Subd. 8. Primary care provider. "Primary care provider" means a health care
56.5professional who specializes in the practice of family medicine, general internal medicine,
56.6obstetrics and gynecology, or general pediatrics and is a licensed physician, a licensed and
56.7certified advanced practice registered nurse, or a licensed physician assistant.
56.8EFFECTIVE DATE.This section is effective the day following final enactment.

56.9    Sec. 67. Minnesota Statutes 2012, section 62Q.01, is amended by adding a subdivision
56.10to read:
56.11    Subd. 9. Dependent child to the limiting age. "Dependent child to the limiting
56.12age" or "dependent children to the limiting age" means those individuals who are eligible
56.13and covered as a dependent child under the terms of a health plan who have not yet
56.14attained 26 years of age. A health plan company must not deny or restrict eligibility
56.15for a dependent child to the limiting age based on financial dependency, residency,
56.16marital status, or student status. For coverage under plans offered by the Minnesota
56.17Comprehensive Health Association, dependent to the limiting age means dependent
56.18as defined in section 62A.302, subdivision 3. Notwithstanding the provisions in this
56.19subdivision, a health plan may include:
56.20(1) eligibility requirements regarding the absence of other health plan coverage as
56.21permitted by the Affordable Care Act for grandfathered plan coverage; or
56.22(2) an age greater than 26 in its policy, contract, or certificate of coverage.
56.23EFFECTIVE DATE.This section is effective the day following final enactment.

56.24    Sec. 68. Minnesota Statutes 2012, section 62Q.021, is amended to read:
56.2562Q.021 FEDERAL ACT; COMPLIANCE REQUIRED.
56.26    Subdivision 1. Compliance with 1996 federal law. Each health plan company shall
56.27comply with the federal Health Insurance Portability and Accountability Act of 1996,
56.28including any federal regulations adopted under that act, to the extent that it imposes a
56.29requirement that applies in this state and that is not also required by the laws of this state.
56.30This section does not require compliance with any provision of the federal act prior to
56.31the effective date provided for that provision in the federal act. The commissioner shall
56.32enforce this section subdivision.
57.1    Subd. 2. Compliance with 2010 federal law. Each health plan company shall
57.2comply with the Affordable Care Act to the extent that it imposes a requirement that
57.3applies in this state but is not required under the laws of this state. This section does not
57.4require compliance with any provision of the Affordable Care Act before the effective
57.5date provided for that provision in the Affordable Care Act. The commissioner shall
57.6enforce this subdivision.
57.7EFFECTIVE DATE.This section is effective the day following final enactment.

57.8    Sec. 69. Minnesota Statutes 2012, section 62Q.17, subdivision 6, is amended to read:
57.9    Subd. 6. Employer-based purchasing pools. Employer-based purchasing
57.10pools must, with respect to small employers as defined in section 62L.02, meet all the
57.11requirements of chapter 62L. The experience of the pool must be pooled and the rates
57.12blended across all groups. Pools may decide to create tiers within the pool, based on
57.13experience of group members. These tiers must be designed within the requirements
57.14of section 62L.08. The governing structure may establish criteria limiting movement
57.15between tiers. Tiers must be phased out within two years of the pool's creation.
57.16EFFECTIVE DATE.This section is effective January 1, 2014.

57.17    Sec. 70. Minnesota Statutes 2012, section 62Q.18, is amended by adding a subdivision
57.18to read:
57.19    Subd. 8. Guaranteed issue. No health plan company shall offer, sell, or issue
57.20any health plan that does not make coverage available on a guaranteed issue basis in
57.21accordance with the Affordable Care Act.
57.22EFFECTIVE DATE.This section is effective January 1, 2014.

57.23    Sec. 71. [62Q.186] PROHIBITION ON RESCISSIONS OF HEALTH PLANS.
57.24    Subdivision 1. Definitions. (a) "Rescission" means a cancellation or discontinuance
57.25of coverage under a health plan that has a retroactive effect.
57.26(b) "Rescission" does not include:
57.27(1) a cancellation or discontinuance of coverage under a health plan if:
57.28(i) the cancellation or discontinuance of coverage has only a prospective effect; or
57.29(ii) the cancellation or discontinuance of coverage is effective retroactively to the
57.30extent it is attributable to a failure to timely pay required premiums or contributions
57.31toward the cost of coverage; or
58.1(2) when the health plan covers only active employees and, if applicable,
58.2dependents and those covered under continuation coverage provisions, the employee
58.3pays no premiums for coverage after termination of employment and the cancellation or
58.4discontinuance of coverage is effective retroactively back to the date of termination of
58.5employment due to a delay in administrative record keeping.
58.6    Subd. 2. Prohibition on rescissions. (a) A health plan company shall not rescind
58.7coverage under a health plan with respect to an individual, including a group to which
58.8the individual belongs or family coverage in which the individual is included, after the
58.9individual is covered under the health plan, unless:
58.10(1) the individual, or a person seeking coverage on behalf of the individual, performs
58.11an act, practice, or omission that constitutes fraud; or
58.12(2) the individual makes an intentional misrepresentation or omission of material
58.13fact, as prohibited by the terms of the health plan.
58.14For purposes of this section, a person seeking coverage on behalf of an individual
58.15does not include an insurance producer or employee or authorized representative of the
58.16health carrier.
58.17(b) This section does not apply to any benefits classified as excepted benefits under
58.18United States Code, title 42, section 300gg-91(c), or regulations enacted thereunder
58.19from time to time.
58.20    Subd. 3. Notice required. A health plan company shall provide at least 30 days'
58.21advance written notice to each individual who would be affected by the proposed rescission
58.22of coverage before coverage under the health plan may be terminated retroactively.
58.23    Subd. 4. Compliance with other restrictions on rescissions. Nothing in this
58.24section allows rescission if rescission would otherwise be prohibited under section
58.2562A.04, subdivision 2, clause (2), or 62A.615.
58.26EFFECTIVE DATE.This section is effective the day following final enactment.

58.27    Sec. 72. Minnesota Statutes 2012, section 62Q.23, is amended to read:
58.2862Q.23 GENERAL SERVICES.
58.29(a) Health plan companies shall comply with all continuation and conversion of
58.30coverage requirements applicable to health maintenance organizations under state or
58.31federal law.
58.32(b) Health plan companies shall comply with sections 62A.047, 62A.27, and any
58.33other coverage required under chapter 62A of newborn infants, dependent children who
58.34do not reside with a covered person to the limiting age as defined in section 62Q.01,
59.1subdivision 9, disabled children and dependents dependent children, and adopted children.
59.2A health plan company providing dependent coverage shall comply with section 62A.302.
59.3(c) Health plan companies shall comply with the equal access requirements of
59.4section 62A.15.
59.5EFFECTIVE DATE.This section is effective the day following final enactment.

59.6    Sec. 73. Minnesota Statutes 2012, section 62Q.43, subdivision 2, is amended to read:
59.7    Subd. 2. Access requirement. Every closed-panel health plan must allow enrollees
59.8who are full-time students under the age of 25 26 years to change their designated clinic or
59.9physician at least once per month, as long as the clinic or physician is part of the health
59.10plan company's statewide clinic or physician network. A health plan company shall not
59.11charge enrollees who choose this option higher premiums or cost sharing than would
59.12otherwise apply to enrollees who do not choose this option. A health plan company may
59.13require enrollees to provide 15 days' written notice of intent to change their designated
59.14clinic or physician.
59.15EFFECTIVE DATE.This section is effective the day following final enactment.

59.16    Sec. 74. [62Q.46] PREVENTIVE ITEMS AND SERVICES.
59.17    Subdivision 1. Coverage for preventive items and services. (a) "Preventive items
59.18and services" has the meaning specified in the Affordable Care Act.
59.19(b) A health plan company must provide coverage for preventive items and services
59.20at a participating provider without imposing cost-sharing requirements, including a
59.21deductible, coinsurance, or co-payment. Nothing in this section prohibits a health
59.22plan company that has a network of providers from excluding coverage or imposing
59.23cost-sharing requirements for preventive items or services that are delivered by an
59.24out-of-network provider.
59.25(c) A health plan company is not required to provide coverage for any items or
59.26services specified in any recommendation or guideline described in paragraph (a) if the
59.27recommendation or guideline is no longer included as a preventive item or service as
59.28defined in paragraph (a). Annually, a health plan company must determine whether any
59.29additional items or services must be covered without cost-sharing requirements or whether
59.30any items or services are no longer required to be covered.
59.31(d) Nothing in this section prevents a health plan company from using reasonable
59.32medical management techniques to determine the frequency, method, treatment, or setting
60.1for a preventive item or service to the extent not specified in the recommendation or
60.2guideline.
60.3(e) This section does not apply to grandfathered plans.
60.4(f) This section does not apply to plans offered by the Minnesota Comprehensive
60.5Health Association.
60.6    Subd. 2. Coverage for office visits in conjunction with preventive items and
60.7services. (a) A health plan company may impose cost-sharing requirements with respect
60.8to an office visit if a preventive item or service is billed separately or is tracked separately
60.9as individual encounter data from the office visit.
60.10(b) A health plan company must not impose cost-sharing requirements with respect
60.11to an office visit if a preventive item or service is not billed separately or is not tracked
60.12separately as individual encounter data from the office visit and the primary purpose of the
60.13office visit is the delivery of the preventive item or service.
60.14(c) A health plan company may impose cost-sharing requirements with respect to
60.15an office visit if a preventive item or service is not billed separately or is not tracked
60.16separately as individual encounter data from the office visit and the primary purpose of the
60.17office visit is not the delivery of the preventive item or service.
60.18    Subd. 3. Additional services not prohibited. Nothing in this section prohibits a
60.19health plan company from providing coverage for preventive items and services in addition
60.20to those specified in the Affordable Care Act, or from denying coverage for preventive
60.21items and services that are not recommended as preventive items and services under the
60.22Affordable Care Act. A health plan company may impose cost-sharing requirements for a
60.23treatment not described in the Affordable Care Act even if the treatment results from a
60.24preventive item or service described in the Affordable Care Act.
60.25EFFECTIVE DATE.This section is effective the day following final enactment.

60.26    Sec. 75. Minnesota Statutes 2012, section 62Q.47, is amended to read:
60.2762Q.47 ALCOHOLISM, MENTAL HEALTH, AND CHEMICAL
60.28DEPENDENCY SERVICES.
60.29    (a) All health plans, as defined in section 62Q.01, that provide coverage for
60.30alcoholism, mental health, or chemical dependency services, must comply with the
60.31requirements of this section.
60.32    (b) Cost-sharing requirements and benefit or service limitations for outpatient
60.33mental health and outpatient chemical dependency and alcoholism services, except for
60.34persons placed in chemical dependency services under Minnesota Rules, parts 9530.6600
61.1to 9530.6660, must not place a greater financial burden on the insured or enrollee, or be
61.2more restrictive than those requirements and limitations for outpatient medical services.
61.3    (c) Cost-sharing requirements and benefit or service limitations for inpatient hospital
61.4mental health and inpatient hospital and residential chemical dependency and alcoholism
61.5services, except for persons placed in chemical dependency services under Minnesota
61.6Rules, parts 9530.6600 to 9530.6660, must not place a greater financial burden on the
61.7insured or enrollee, or be more restrictive than those requirements and limitations for
61.8inpatient hospital medical services.
61.9    (d) All health plans must meet the requirements of the federal Mental Health Parity
61.10Act of 1996, Public Law 104-204; Paul Wellstone and Pete Domenici Mental Health
61.11Parity and Addiction Equity Act of 2008; the Affordable Care Act; and any amendments
61.12to, and federal guidance or regulations issued under, those acts.
61.13EFFECTIVE DATE.This section is effective the day following final enactment.

61.14    Sec. 76. Minnesota Statutes 2012, section 62Q.52, is amended to read:
61.1562Q.52 DIRECT ACCESS TO OBSTETRIC AND GYNECOLOGIC
61.16SERVICES.
61.17    Subdivision 1. Direct access. (a) Health plan companies shall allow female
61.18enrollees direct access to obstetricians and gynecologists providers who specialize in
61.19obstetrics and gynecology for the following services:
61.20(1) annual preventive health examinations, which shall include a gynecologic
61.21examination, and any subsequent obstetric or gynecologic visits determined to be medically
61.22necessary by the examining obstetrician or gynecologist, based upon the findings of the
61.23examination evaluation and necessary treatment for obstetric conditions or emergencies;
61.24(2) maternity care; and
61.25(3) evaluation and necessary treatment for acute gynecologic conditions or
61.26emergencies, including annual preventive health examinations.
61.27(b) For purposes of this section, "direct access" means that a female enrollee may
61.28obtain the obstetric and gynecologic services specified in paragraph (a) from obstetricians
61.29and gynecologists providers who specialize in obstetrics and gynecology in the enrollee's
61.30network without a referral from, or prior approval through a primary care provider,
61.31another physician, the health plan company, or its representatives.
61.32(c) The health plan company shall treat the provision of obstetrical and gynecological
61.33care and the ordering of related obstetrical and gynecological items and services, pursuant
62.1to paragraph (a), by a participating health care provider who specializes in obstetrics or
62.2gynecology as the authorization of a primary care provider.
62.3(d) The health plan company may require the health care provider to agree to
62.4otherwise adhere to the health plan company's policies and procedures, including
62.5procedures for obtaining prior authorization and for providing services in accordance with
62.6a treatment plan, if any, approved by the health plan company.
62.7(c) (e) Health plan companies shall not require higher co-payments, coinsurance,
62.8deductibles, or other enrollee cost-sharing for direct access.
62.9(d) (f) This section applies only to services described in paragraph (a) that are
62.10covered by the enrollee's coverage, but coverage of a preventive health examination for
62.11female enrollees must not exclude coverage of a gynecologic examination.
62.12(g) For purposes of this section, a health care provider who specializes in obstetrics
62.13or gynecology means any individual, including an individual other than a physician, who
62.14is authorized under state law to provide obstetrical or gynecological care.
62.15(h) This section does not:
62.16(1) waive any exclusions of coverage under the terms and conditions of the health
62.17plan with respect to coverage of obstetrical or gynecological care; or
62.18(2) preclude the health plan company from requiring that the participating health
62.19care provider providing obstetrical or gynecological care notify the primary care provider
62.20or the health plan company of treatment decisions.
62.21    Subd. 2. Notice. A health plan company shall provide notice to enrollees of the
62.22provisions of subdivision 1 in accordance with the requirements of the Affordable Care Act.
62.23    Subd. 3. Enforcement. The commissioner of health shall enforce this section.
62.24EFFECTIVE DATE.This section is effective the day following final enactment.

62.25    Sec. 77. [62Q.526] COVERAGE FOR PARTICIPATION IN APPROVED
62.26CLINICAL TRIALS.
62.27    Subdivision 1. Definitions. As used in this section, the following definitions apply:
62.28(a) "Approved clinical trial" means a phase I, phase II, phase III, or phase IV clinical
62.29trial that is conducted in relation to the prevention, detection, or treatment of cancer or
62.30a life-threatening condition and is not designed exclusively to test toxicity or disease
62.31pathophysiology and must be:
62.32(1) conducted under an investigational new drug application reviewed by the United
62.33States Food and Drug Administration (FDA);
62.34(2) exempt from obtaining an investigational new drug application; or
62.35(3) approved or funded by:
63.1(i) the National Institutes of Health (NIH), the Centers for Disease Control and
63.2Prevention, the Agency for Health Care Research and Quality, the Centers for Medicare
63.3and Medicaid Services, or a cooperating group or center of any of the entities described in
63.4this item;
63.5(ii) a cooperative group or center of the United States Department of Defense or the
63.6United States Department of Veterans Affairs;
63.7(iii) a qualified nongovernmental research entity identified in the guidelines issued
63.8by the NIH for center support grants; or
63.9(iv) the United States Departments of Veterans Affairs, Defense, or Energy if the
63.10trial has been reviewed or approved through a system of peer review determined by the
63.11secretary to:
63.12(A) be comparable to the system of peer review of studies and investigations used by
63.13the NIH; and
63.14(B) provide an unbiased scientific review by qualified individuals who have no
63.15interest in the outcome of the review.
63.16(b) "Qualified individual" means an individual with health plan coverage who is
63.17eligible to participate in an approved clinical trial according to the trial protocol for the
63.18treatment of cancer or a life-threatening condition because:
63.19(1) the referring health care professional is participating in the trial and has
63.20concluded that the individual's participation in the trial would be appropriate; or
63.21(2) the individual provides medical and scientific information establishing that
63.22the individual's participation in the trial is appropriate because the individual meets the
63.23conditions described in the trial protocol.
63.24(c)(1) "Routine patient costs" includes all items and services covered by the health
63.25benefit plan of individual market health insurance coverage when the items or services
63.26are typically covered for an enrollee who is not a qualified individual enrolled in an
63.27approved clinical trial.
63.28(2) Routine patient costs does not include:
63.29(i) an investigational item, device, or service that is part of the trial;
63.30(ii) an item or service provided solely to satisfy data collection and analysis needs for
63.31the trial if the item or service is not used in the direct clinical management of the patient;
63.32(iii) a service that is clearly inconsistent with widely accepted and established
63.33standards of care for the individual's diagnosis; or
63.34(iv) an item or service customarily provided and paid for by the sponsor of a trial.
63.35    Subd. 2. Prohibited acts. A health plan company that offers a health plan to a
63.36Minnesota resident may not:
64.1(1) deny participation by a qualified individual in an approved clinical trial;
64.2(2) deny, limit, or impose additional conditions on the coverage of routine patient
64.3costs for items or services furnished in connection with participation in the trial; or
64.4(3) discriminate against an individual on the basis of an individual's participation in
64.5an approved clinical trial.
64.6    Subd. 3. Network plan conditions. A health plan company that designates a
64.7network or networks of contracted providers may require a qualified individual who
64.8wishes to participate in an approved clinical trial to participate in a trial that is offered
64.9through a health care provider who is part of the plan's network if the provider is
64.10participating in the trial and the provider accepts the individual as a participant in the trial.
64.11    Subd. 4. Application to clinical trials outside of the state. This section applies
64.12to a qualified individual residing in this state who participates in an approved clinical
64.13trial that is conducted outside of this state.
64.14    Subd. 5. Construction. (a) This section shall not be construed to require a health
64.15plan company offering health plan coverage through a network or networks of contracted
64.16providers to provide benefits for routine patient costs if the services are provided outside
64.17of the plan's network unless the out-of-network benefits are otherwise provided under
64.18the coverage.
64.19(b) This section shall not be construed to limit a health plan company's coverage
64.20with respect to clinical trials.
64.21(c) This section shall apply to all health plan companies offering a health plan to a
64.22Minnesota resident, unless otherwise amended by federal regulations under the Affordable
64.23Care Act.
64.24EFFECTIVE DATE.This section is effective January 1, 2014.

64.25    Sec. 78. Minnesota Statutes 2012, section 62Q.55, is amended to read:
64.2662Q.55 EMERGENCY SERVICES.
64.27    Subdivision 1. Access to emergency services. (a) Enrollees have the right to
64.28available and accessible emergency services, 24 hours a day and seven days a week.
64.29The health plan company shall inform its enrollees how to obtain emergency care and,
64.30if prior authorization for emergency services is required, shall make available a toll-free
64.31number, which is answered 24 hours a day, to answer questions about emergency services
64.32and to receive reports and provide authorizations, where appropriate, for treatment of
64.33emergency medical conditions. Emergency services shall be covered whether provided by
64.34participating or nonparticipating providers and whether provided within or outside the
65.1health plan company's service area. In reviewing a denial for coverage of emergency
65.2services, the health plan company shall take the following factors into consideration:
65.3(1) a reasonable layperson's belief that the circumstances required immediate medical
65.4care that could not wait until the next working day or next available clinic appointment;
65.5(2) the time of day and day of the week the care was provided;
65.6(3) the presenting symptoms, including, but not limited to, severe pain, to ensure
65.7that the decision to reimburse the emergency care is not made solely on the basis of the
65.8actual diagnosis;
65.9(4) the enrollee's efforts to follow the health plan company's established procedures
65.10for obtaining emergency care; and
65.11(5) any circumstances that precluded use of the health plan company's established
65.12procedures for obtaining emergency care.
65.13(b) The health plan company may require enrollees to notify the health plan
65.14company of nonreferred emergency care as soon as possible, but not later than 48 hours,
65.15after the emergency care is initially provided. However, emergency care which would
65.16have been covered under the contract had notice been provided within the set time frame
65.17must be covered.
65.18(c) Notwithstanding paragraphs (a) and (b), a health plan company, health insurer, or
65.19health coverage plan that is in compliance with the rules regarding accessibility of services
65.20adopted under section 62D.20 is in compliance with this section.
65.21    Subd. 2. Emergency medical condition. For purposes of this section, "emergency
65.22medical condition" means a medical condition manifesting itself by acute symptoms of
65.23sufficient severity, including severe pain, such that a prudent layperson, who possesses
65.24an average knowledge of health and medicine, could reasonably expect the absence of
65.25immediate medical attention to result in a condition described in clause (i), (ii), or (iii), of
65.26section 1867(e)(1)(A) of the Social Security Act.
65.27    Subd. 3. Emergency services. As used in this section, "emergency services" means,
65.28with respect to an emergency medical condition:
65.29(1) a medical screening examination, as required under section 1867 of the Social
65.30Security Act, that is within the capability of the emergency department of a hospital,
65.31including ancillary services routinely available to the emergency department to evaluate
65.32such emergency medical condition; and
65.33(2) within the capabilities of the staff and facilities available at the hospital, such
65.34further medical examination and treatment as are required under section 1867 of the
65.35Social Security Act to stabilize the patient.
66.1    Subd. 4. Stabilize. For purposes of this section, "stabilize," with respect to an
66.2emergency medical condition, has the meaning given in section 1867(e)(3) of the Social
66.3Security Act, United States Code, title 42, section 1395dd(e)(3).
66.4    Subd. 5. Coverage restrictions or limitations. If emergency services are provided
66.5by a nonparticipating provider, with or without prior authorization, the health plan
66.6company shall not impose coverage restrictions or limitations that are more restrictive
66.7than apply to emergency services received from a participating provider. Cost-sharing
66.8requirements that apply to emergency services received out-of-network must be the same
66.9as the cost-sharing requirements that apply to services received in-network.
66.10EFFECTIVE DATE.This section is effective the day following final enactment.

66.11    Sec. 79. [62Q.57] DESIGNATION OF PRIMARY CARE PROVIDER.
66.12    Subdivision 1. Choice of primary care provider. (a) If a health plan company
66.13offering a group health plan, or an individual health plan that is not a grandfathered plan,
66.14requires or provides for the designation by an enrollee of a participating primary care
66.15provider, the health plan company shall permit each enrollee to:
66.16(1) designate any participating primary care provider available to accept the
66.17enrollee; and
66.18(2) for a child, designate any participating physician who specializes in pediatrics as
66.19the child's primary care provider and is available to accept the child.
66.20(b) This section does not waive any exclusions of coverage under the terms and
66.21conditions of the health plan with respect to coverage of pediatric care.
66.22    Subd. 2. Notice. A health plan company shall provide notice to enrollees of the
66.23provisions of subdivision 1 in accordance with the requirements of the Affordable Care Act.
66.24    Subd. 3. Enforcement. The commissioner shall enforce this section.
66.25EFFECTIVE DATE.This section is effective the day following final enactment.

66.26    Sec. 80. [62Q.677] LIFETIME AND ANNUAL LIMITS.
66.27    Subdivision 1. Applicability and scope. Except as provided in subdivision 2,
66.28this section applies to a health plan company providing coverage under an individual or
66.29group health plan. For purposes of this section, essential health benefits is defined under
66.30section 62Q.81.
66.31    Subd. 2. Grandfathered plan limits. (a) The prohibition on lifetime limits applies
66.32to grandfathered plans providing individual health plan coverage or group health plan
66.33coverage.
67.1(b) The prohibition and limits on annual limits apply to grandfathered plans
67.2providing group health plan coverage, but do not apply to grandfathered plans providing
67.3individual health plan coverage.
67.4    Subd. 3. Prohibition on lifetime and annual limits. (a) Except as provided in
67.5subdivisions 4 and 5, a health plan company offering coverage under an individual or
67.6group health plan shall not establish a lifetime limit on the dollar amount of essential
67.7health benefits for any individual.
67.8(b) Except as provided in subdivisions 4, 5, and 6, a health plan company shall
67.9not establish any annual limit on the dollar amount of essential health benefits for any
67.10individual.
67.11    Subd. 4. Nonessential benefits; out-of-network providers. (a) Subdivision 3 does
67.12not prevent a health plan company from placing annual or lifetime dollar limits for any
67.13individual on specific covered benefits that are not essential health benefits as defined in
67.14section 62Q.81, subdivision 4, to the extent that the limits are otherwise permitted under
67.15applicable federal or state law.
67.16(b) Subdivision 3 does not prevent a health plan company from placing an annual or
67.17lifetime limit for services provided by out-of-network providers.
67.18    Subd. 5. Excluded benefits. This section does not prohibit a health plan company
67.19from excluding all benefits for a given condition.
67.20    Subd. 6. Annual limits prior to January 1, 2014. For plan or policy years
67.21beginning before January 1, 2014, for any individual, a health plan company may establish
67.22an annual limit on the dollar amount of benefits that are essential health benefits provided
67.23the limit is no less than the following:
67.24(1) for a plan or policy year beginning after September 22, 2010, but before
67.25September 23, 2011, $750,000;
67.26(2) for a plan or policy year beginning after September 22, 2011, but before
67.27September 23, 2012, $1,250,000; and
67.28(3) for a plan or policy year beginning after September 22, 2012, but before January
67.291, 2014, $2,000,000.
67.30In determining whether an individual has received benefits that meet or exceed the
67.31allowable limits, a health plan company shall take into account only essential health
67.32benefits.
67.33    Subd. 7. Waivers. For plan or policy years beginning before January 1, 2014, a
67.34health plan is exempt from the annual limit requirements if the health plan is approved for
67.35a waiver from the requirements by the United States Department of Health and Human
68.1Services, but the exemption only applies for the specified period of time that the waiver
68.2from the United States Department of Health and Human Services is applicable.
68.3    Subd. 8. Notices. (a) At the time a health plan company receives a waiver from the
68.4United States Department of Health and Human Services, the health plan company shall
68.5notify prospective applicants and affected policyholders and the commissioner in each
68.6state where prospective applicants and any affected insured are known to reside.
68.7(b) At the time the waiver expires or is otherwise no longer in effect, the health plan
68.8company shall notify affected policyholders and the commissioner in each state where
68.9any affected insured is known to reside.
68.10    Subd. 9. Reinstatement. A health plan company shall comply with all provisions of
68.11the Affordable Care Act with regard to reinstatement of coverage for individuals whose
68.12coverage or benefits under a health plan ended by reason of reaching a lifetime dollar limit
68.13on the dollar value of all benefits for the individual.
68.14    Subd. 10. Compliance. This section does not require compliance with any
68.15provision of the Affordable Care Act before the effective date provided for that provision
68.16in the Affordable Care Act. The commissioner shall enforce this section.
68.17EFFECTIVE DATE.This section is effective the day following final enactment.

68.18    Sec. 81. Minnesota Statutes 2012, section 62Q.68, subdivision 1, is amended to read:
68.19    Subdivision 1. Application. For purposes of sections 62Q.68 to 62Q.72, the terms
68.20defined in this section have the meanings given them. For purposes of sections 62Q.69
68.21and 62Q.70, the term "health plan company" does not include an insurance company
68.22licensed under chapter 60A to offer, sell, or issue a policy of accident and sickness
68.23insurance as defined in section 62A.01 or a nonprofit health service plan corporation
68.24regulated under chapter 62C that only provides dental coverage or vision coverage. For
68.25purposes of sections 62Q.69 through 62Q.73, the term "health plan company" does
68.26not include the Comprehensive Health Association created under chapter 62E. Section
68.2762Q.70 does not apply to individual coverage. However, a health plan company offering
68.28individual coverage may, pursuant to section 62Q.69, subdivision 3, paragraph (c), follow
68.29the process outlined in section 62Q.70.
68.30EFFECTIVE DATE.This section is effective the day following final enactment.

68.31    Sec. 82. Minnesota Statutes 2012, section 62Q.69, subdivision 3, is amended to read:
68.32    Subd. 3. Notification of complaint decisions. (a) The health plan company must
68.33notify the complainant in writing of its decision and the reasons for it as soon as practical
69.1but in no case later than 30 days after receipt of a written complaint. If the health plan
69.2company cannot make a decision within 30 days due to circumstances outside the control
69.3of the health plan company, the health plan company may take up to 14 additional days to
69.4notify the complainant of its decision. If the health plan company takes any additional
69.5days beyond the initial 30-day period to make its decision, it must inform the complainant,
69.6in advance, of the extension and the reasons for the extension.
69.7(b) For group health plans, if the decision is partially or wholly adverse to the
69.8complainant, the notification must inform the complainant of the right to appeal the
69.9decision to the health plan company's internal appeal process described in section 62Q.70
69.10and the procedure for initiating an appeal.
69.11(c) For individual health plans, if the decision is partially or wholly adverse to
69.12the complainant, the notification must inform the complainant of the right to submit the
69.13complaint decision to the external review process described in section 62Q.73 and the
69.14procedure for initiating the external review process. Notwithstanding the provisions in
69.15this subdivision, a health plan company offering individual coverage may instead follow
69.16the process for group health plans outlined in paragraph (b).
69.17(c) (d) The notification must also inform the complainant of the right to submit the
69.18complaint at any time to either the commissioner of health or commerce for investigation
69.19and the toll-free telephone number of the appropriate commissioner.
69.20EFFECTIVE DATE.This section is effective the day following final enactment.

69.21    Sec. 83. Minnesota Statutes 2012, section 62Q.70, subdivision 1, is amended to read:
69.22    Subdivision 1. Establishment. (a) Each health plan company shall establish an
69.23internal appeal process for reviewing a health plan company's decision regarding a
69.24complaint filed in accordance with section 62Q.69. The appeal process must meet the
69.25requirements of this section. This section applies only to group health plans. However,
69.26a health plan company offering individual coverage may, pursuant to section 62Q.69,
69.27subdivision 3, paragraph (c), follow the process outlined in this section.
69.28(b) The person or persons with authority to resolve or recommend the resolution of
69.29the internal appeal must not be solely the same person or persons who made the complaint
69.30decision under section 62Q.69.
69.31(c) The internal appeal process must permit the enrollee to review the information
69.32relied upon in the course of the appeal and the receipt of testimony, correspondence,
69.33explanations, or other information from the complainant, staff persons, administrators,
69.34providers, or other persons as deemed necessary by the person or persons investigating or
69.35presiding over the appeal.
70.1(d) The enrollee must be allowed to receive continued coverage pending the
70.2outcome of the appeals process.
70.3EFFECTIVE DATE.This section is effective the day following final enactment.

70.4    Sec. 84. Minnesota Statutes 2012, section 62Q.70, subdivision 2, is amended to read:
70.5    Subd. 2. Procedures for filing an appeal. The health plan company must provide
70.6notice to enrollees of its internal appeals process in a culturally and linguistically
70.7appropriate manner consistent with the provisions of the Affordable Care Act. If a
70.8complainant notifies the health plan company of the complainant's desire to appeal the
70.9health plan company's decision regarding the complaint through the internal appeal
70.10process, the health plan company must provide the complainant the option for the appeal
70.11to occur either in writing or by hearing.
70.12EFFECTIVE DATE.This section is effective the day following final enactment.

70.13    Sec. 85. Minnesota Statutes 2012, section 62Q.71, is amended to read:
70.1462Q.71 NOTICE TO ENROLLEES.
70.15Each health plan company shall provide to enrollees a clear and concise description
70.16of its complaint resolution procedure, if applicable under section 62Q.68, subdivision 1,
70.17and the procedure used for utilization review as defined under chapter 62M as part of
70.18the member handbook, subscriber contract, or certificate of coverage. If the health plan
70.19company does not issue a member handbook, the health plan company may provide
70.20the description in another written document. The description must specifically inform
70.21enrollees:
70.22(1) how to submit a complaint to the health plan company;
70.23(2) if the health plan includes utilization review requirements, how to notify the
70.24utilization review organization in a timely manner and how to obtain certification for
70.25health care services;
70.26(3) how to request an appeal either through the procedures described in sections
70.2762Q.69 and section 62Q.70, if applicable, or through the procedures described in chapter
70.2862M;
70.29(4) of the right to file a complaint with either the commissioner of health or
70.30commerce at any time during the complaint and appeal process;
70.31(5) of the toll-free telephone number of the appropriate commissioner; and
70.32(6) of the right, for individual and group coverage, to obtain an external review
70.33under section 62Q.73 and a description of when and how that right may be exercised.,
71.1including that under most circumstances an enrollee must exhaust the internal complaint
71.2or appeal process prior to external review. However, an enrollee may proceed to external
71.3review without exhausting the internal complaint or appeal process under the following
71.4circumstances:
71.5(i) the health plan company waives the exhaustion requirement;
71.6(ii) the health plan company is considered to have waived the exhaustion requirement
71.7by failing to substantially comply with any requirements including, but not limited to,
71.8time limits for internal complaints or appeals; or
71.9(iii) the enrollee has applied for an expedited external review at the same time the
71.10enrollee qualifies for and has applied for an expedited internal review under chapter 62M.
71.11EFFECTIVE DATE.This section is effective the day following final enactment.

71.12    Sec. 86. Minnesota Statutes 2012, section 62Q.73, is amended to read:
71.1362Q.73 EXTERNAL REVIEW OF ADVERSE DETERMINATIONS.
71.14    Subdivision 1. Definition. For purposes of this section, "adverse determination"
71.15means:
71.16(1) for individual health plans, a complaint decision relating to a health care service
71.17or claim that is partially or wholly adverse to the complainant;
71.18(2) an individual health plan that is grandfathered plan coverage may instead apply
71.19the definition of adverse determination for group coverage in clause (3);
71.20(3) for group health plans, a complaint decision relating to a health care service or
71.21claim that has been appealed in accordance with section 62Q.70 and the appeal decision is
71.22partially or wholly adverse to the complainant;
71.23(2) (4) any initial determination not to certify that has been appealed in accordance
71.24with section 62M.06 and the appeal did not reverse the initial determination not to certify; or
71.25(3) (5) a decision relating to a health care service made by a health plan company
71.26licensed under chapter 60A that denies the service on the basis that the service was not
71.27medically necessary.; or
71.28(6) the enrollee has met the requirements of subdivision 6, paragraph (e).
71.29An adverse determination does not include complaints relating to fraudulent marketing
71.30practices or agent misrepresentation.
71.31    Subd. 2. Exception. (a) This section does not apply to governmental programs
71.32except as permitted under paragraph (b). For purposes of this subdivision, "governmental
71.33programs" means the prepaid medical assistance program, the MinnesotaCare program,
72.1the prepaid general assistance medical care program, the demonstration project for people
72.2with disabilities, and the federal Medicare program.
72.3(b) In the course of a recipient's appeal of a medical determination to the
72.4commissioner of human services under section 256.045, the recipient may request an
72.5expert medical opinion be arranged by the external review entity under contract to provide
72.6independent external reviews under this section. If such a request is made, the cost of the
72.7review shall be paid by the commissioner of human services. Any medical opinion obtained
72.8under this paragraph shall only be used by a state human services referee as evidence in
72.9the recipient's appeal to the commissioner of human services under section 256.045.
72.10(c) Nothing in this subdivision shall be construed to limit or restrict the appeal rights
72.11provided in section 256.045 for governmental program recipients.
72.12    Subd. 3. Right to external review. (a) Any enrollee or anyone acting on behalf
72.13of an enrollee who has received an adverse determination may submit a written request
72.14for an external review of the adverse determination, if applicable under section 62Q.68,
72.15subdivision 1
, or 62M.06, to the commissioner of health if the request involves a health
72.16plan company regulated by that commissioner or to the commissioner of commerce if the
72.17request involves a health plan company regulated by that commissioner. Notification of
72.18the enrollee's right to external review must accompany the denial issued by the insurer.
72.19The written request must be accompanied by a filing fee of $25. The fee may be waived
72.20by the commissioner of health or commerce in cases of financial hardship and must be
72.21refunded if the adverse determination is completely reversed. No enrollee may be subject
72.22to filing fees totaling more than $75 during a plan year for group coverage or policy year
72.23for individual coverage.
72.24(b) Nothing in this section requires the commissioner of health or commerce to
72.25independently investigate an adverse determination referred for independent external
72.26review.
72.27(c) If an enrollee requests an external review, the health plan company must
72.28participate in the external review. The cost of the external review in excess of the filing
72.29fee described in paragraph (a) shall be borne by the health plan company.
72.30(d) The enrollee must request external review within six months from the date of
72.31the adverse determination.
72.32    Subd. 4. Contract. Pursuant to a request for proposal, the commissioner of
72.33administration, in consultation with the commissioners of health and commerce, shall
72.34contract with an organization at least three organizations or business entity entities to
72.35provide independent external reviews of all adverse determinations submitted for external
73.1review. The contract shall ensure that the fees for services rendered in connection with the
73.2reviews be are reasonable.
73.3    Subd. 5. Criteria. (a) The request for proposal must require that the entity
73.4demonstrate:
73.5(1) no conflicts of interest in that it is not owned, a subsidiary of, or affiliated
73.6with a health plan company or, utilization review organization, or a trade organization
73.7of health care providers;
73.8(2) an expertise in dispute resolution;
73.9(3) an expertise in health-related law;
73.10(4) an ability to conduct reviews using a variety of alternative dispute resolution
73.11procedures depending upon the nature of the dispute;
73.12(5) an ability to maintain written records, for at least three years, regarding reviews
73.13conducted and provide data to the commissioners of health and commerce upon request on
73.14reviews conducted; and
73.15(6) an ability to ensure confidentiality of medical records and other enrollee
73.16information.;
73.17(7) accreditation by nationally recognized private accrediting organization; and
73.18(8) the ability to provide an expedited external review process.
73.19(b) The commissioner of administration shall take into consideration, in awarding
73.20the contract according to subdivision 4, any national accreditation standards that pertain to
73.21an external review entity.
73.22    Subd. 6. Process. (a) Upon receiving a request for an external review, the
73.23 commissioner shall assign an external review entity on a random basis. The assigned
73.24 external review entity must provide immediate notice of the review to the enrollee and to
73.25the health plan company. Within ten business days of receiving notice of the review, the
73.26health plan company and the enrollee must provide the assigned external review entity
73.27with any information that they wish to be considered. Each party shall be provided an
73.28opportunity to present its version of the facts and arguments. The assigned external review
73.29entity must furnish to the health plan company any additional information submitted by
73.30the enrollee within one business day of receipt. An enrollee may be assisted or represented
73.31by a person of the enrollee's choice.
73.32(b) As part of the external review process, any aspect of an external review involving
73.33a medical determination must be performed by a health care professional with expertise in
73.34the medical issue being reviewed.
73.35(c) An external review shall be made as soon as practical but in no case later than 40
73.36 45 days after receiving the request for an external review and must promptly send written
74.1notice of the decision and the reasons for it to the enrollee, the health plan company, and
74.2the commissioner who is responsible for regulating the health plan company.
74.3(d) The external review entity and the clinical reviewer assigned must not have a
74.4material professional, familial, or financial conflict of interest with:
74.5(1) the health plan company that is the subject of the external review;
74.6(2) the enrollee, or any parties related to the enrollee, whose treatment is the subject
74.7of the external review;
74.8(3) any officer, director, or management employee of the health plan company;
74.9(4) a plan administrator, plan fiduciaries, or plan employees;
74.10(5) the health care provider, the health care provider's group, or practice association
74.11recommending treatment that is the subject of the external review;
74.12(6) the facility at which the recommended treatment would be provided; or
74.13(7) the developer or manufacturer of the principal drug, device, procedure, or other
74.14therapy being recommended.
74.15(e)(1) An expedited external review must be provided if the enrollee requests it
74.16after receiving:
74.17(i) an adverse determination that involves a medical condition for which the time
74.18frame for completion of an expedited internal appeal would seriously jeopardize the life
74.19or health of the enrollee or would jeopardize the enrollee's ability to regain maximum
74.20function and the enrollee has simultaneously requested an expedited internal appeal;
74.21(ii) an adverse determination that concerns an admission, availability of care,
74.22continued stay, or health care service for which the enrollee received emergency services
74.23but has not been discharged from a facility; or
74.24(iii) an adverse determination that involves a medical condition for which the
74.25standard external review time would seriously jeopardize the life or health of the enrollee
74.26or jeopardize the enrollee's ability to regain maximum function.
74.27(2) The external review entity must make its expedited determination to uphold or
74.28reverse the adverse determination as expeditiously as possible but within no more than 72
74.29hours after the receipt of the request for expedited review and notify the enrollee and the
74.30health plan company of the determination.
74.31(3) If the external review entity's notification is not in writing, the external review
74.32entity must provide written confirmation of the determination within 48 hours of the
74.33notification.
74.34    Subd. 7. Standards of review. (a) For an external review of any issue in an adverse
74.35determination that does not require a medical necessity determination, the external review
75.1must be based on whether the adverse determination was in compliance with the enrollee's
75.2health benefit plan.
75.3(b) For an external review of any issue in an adverse determination by a health plan
75.4company licensed under chapter 62D that requires a medical necessity determination, the
75.5external review must determine whether the adverse determination was consistent with the
75.6definition of medically necessary care in Minnesota Rules, part 4685.0100, subpart 9b.
75.7(c) For an external review of any issue in an adverse determination by a health plan
75.8company, other than a health plan company licensed under chapter 62D, that requires a
75.9medical necessity determination, the external review must determine whether the adverse
75.10determination was consistent with the definition of medically necessary care in section
75.1162Q.53, subdivision 2 .
75.12(d) For an external review of an adverse determination involving experimental
75.13or investigational treatment, the external review entity must base its decision on all
75.14documents submitted by the health plan company and enrollee, including medical
75.15records, the attending physician or health care professional's recommendation, consulting
75.16reports from health care professionals, the terms of coverage, federal Food and Drug
75.17Administration approval, and medical or scientific evidence or evidence-based standards.
75.18    Subd. 8. Effects of external review. A decision rendered under this section shall
75.19be nonbinding on the enrollee and binding on the health plan company. The health plan
75.20company may seek judicial review of the decision on the grounds that the decision was
75.21arbitrary and capricious or involved an abuse of discretion.
75.22    Subd. 9. Immunity from civil liability. A person who participates in an external
75.23review by investigating, reviewing materials, providing technical expertise, or rendering a
75.24decision shall not be civilly liable for any action that is taken in good faith, that is within
75.25the scope of the person's duties, and that does not constitute willful or reckless misconduct.
75.26    Subd. 10. Data reporting. The commissioners shall make available to the public,
75.27upon request, summary data on the decisions rendered under this section, including the
75.28number of reviews heard and decided and the final outcomes. Any data released to the
75.29public must not individually identify the enrollee initiating the request for external review.
75.30EFFECTIVE DATE.This section is effective the day following final enactment.

75.31    Sec. 87. Minnesota Statutes 2012, section 62Q.75, subdivision 1, is amended to read:
75.32    Subdivision 1. Definitions. (a) For purposes of this section, the following terms
75.33have the meanings given to them.
75.34(b) "Clean claim" means a claim that has no defect or impropriety, including any lack
75.35of any required substantiating documentation, including, but not limited to, coordination
76.1of benefits information, or particular circumstance requiring special treatment that
76.2prevents timely payment from being made on a claim under this section. A special
76.3circumstance includes, but is not limited to, a claim held pending payment of an overdue
76.4premium for the time period during which the expense was incurred as allowed by the
76.5Affordable Care Act. Nothing in this section alters an enrollee's obligation to disclose
76.6information as required by law.
76.7(c) "Third-party administrator" means a third-party administrator or other entity
76.8subject to section 60A.23, subdivision 8, and Minnesota Rules, chapter 2767.
76.9EFFECTIVE DATE.This section is effective January 1, 2014.

76.10    Sec. 88. Minnesota Statutes 2012, section 62Q.80, subdivision 2, is amended to read:
76.11    Subd. 2. Definitions. For purposes of this section, the following definitions apply:
76.12(a) "Community-based" means located in or primarily relating to the community,
76.13as determined by the board of a community-based health initiative that is served by the
76.14community-based health care coverage program.
76.15(b) "Community-based health care coverage program" or "program" means a
76.16program administered by a community-based health initiative that provides health care
76.17services through provider members of a community-based health network or combination
76.18of networks to eligible individuals and their dependents who are enrolled in the program.
76.19(c) "Community-based health initiative" or "initiative" means a nonprofit corporation
76.20that is governed by a board that has at least 80 percent of its members residing in the
76.21community and includes representatives of the participating network providers and
76.22employers, or a county-based purchasing organization as defined in section 256B.692.
76.23(d) "Community-based health network" means a contract-based network of health
76.24care providers organized by the community-based health initiative to provide or support
76.25the delivery of health care services to enrollees of the community-based health care
76.26coverage program on a risk-sharing or nonrisk-sharing basis.
76.27(e) "Dependent" means an eligible employee's spouse or unmarried child who
76.28is under the age of 19 26 years.
76.29EFFECTIVE DATE.This section is effective the day following final enactment.

76.30    Sec. 89. [62Q.81] ESSENTIAL HEALTH BENEFIT PACKAGE
76.31REQUIREMENTS.
76.32    Subdivision 1. Essential health benefits package. (a) Health plan companies
76.33offering individual and small group health plans must include the essential health benefits
77.1package required under section 1302(a) of the Affordable Care Act and as described
77.2in this subdivision.
77.3    (b) The essential health benefits package means coverage that:
77.4    (1) provides essential health benefits as outlined in the Affordable Care Act;
77.5    (2) limits cost-sharing for such coverage in accordance with the Affordable Care
77.6Act, as described in subdivision 2; and
77.7    (3) subject to subdivision 3, provides bronze, silver, gold, or platinum level of
77.8coverage in accordance with the Affordable Care Act.
77.9    Subd. 2. Coverage for enrollees under the age of 21. If a health plan company
77.10offers health plans in any level of coverage specified under section 1302(d) of the
77.11Affordable Care Act, as described in subdivision 1, paragraph (b), clause (3), the health
77.12plan company shall also offer coverage in that level to individuals who have not attained
77.1321 years of age as of the beginning of a policy year.
77.14    Subd. 3. Alternative compliance for catastrophic plans. A health plan company
77.15that does not provide an individual or small group health plan in the bronze, silver, gold,
77.16or platinum level of coverage, as described in subdivision 1, paragraph (b), clause (3),
77.17shall be treated as meeting the requirements of section 1302(d) of the Affordable Care Act
77.18with respect to any policy year if the health plan company provides a catastrophic plan
77.19that meets the requirements of section 1302(e) of the Affordable Care Act.
77.20    Subd. 4. Essential health benefits; definition. For purposes of this section,
77.21"essential health benefits" has the meaning given under section 1302(b) of the Affordable
77.22Care Act and includes:
77.23    (1) ambulatory patient services;
77.24    (2) emergency services;
77.25    (3) hospitalization;
77.26    (4) laboratory services;
77.27    (5) maternity and newborn care;
77.28    (6) mental health and substance use disorder services, including behavioral health
77.29treatment;
77.30    (7) pediatric services, including oral and vision care;
77.31    (8) prescription drugs;
77.32    (9) preventive and wellness services and chronic disease management;
77.33    (10) rehabilitative and habilitative services and devices; and
77.34    (11) additional essential health benefits included in the EHB-benchmark plan, as
77.35defined under the Affordable Care Act.
78.1    Subd. 5. Exception. This section does not apply to a dental plan described in
78.2section 1311(d)(2)(B)(ii) of the Affordable Care Act.
78.3EFFECTIVE DATE.This section is effective January 1, 2014.

78.4    Sec. 90. [62Q.82] BENEFITS AND COVERAGE EXPLANATION.
78.5    Subdivision 1. Summary. Health plan companies offering health plans shall provide
78.6a summary of benefits and coverage explanation as required by the Affordable Care Act to:
78.7(1) an applicant at the time of application;
78.8(2) an enrollee prior to the time of enrollment or reenrollment, as applicable; and
78.9(3) a policyholder at the time of issuance of the policy.
78.10    Subd. 2. Compliance. A health plan company described in subdivision 1 shall be
78.11deemed to have complied with subdivision 1 if the summary of benefits and coverage
78.12explanation is provided in paper or electronic form as required under the Affordable
78.13Care Act.
78.14    Subd. 3. Notice of modification. Except in connection with a policy renewal or
78.15reissuance, if a health plan company makes any material modifications in any of the
78.16terms of the coverage, as defined for purposes of section 102 of the federal Employee
78.17Retirement Income Security Act of 1974, as amended, that is not reflected in the most
78.18recently provided summary of benefits and coverage explanation, the health plan company
78.19shall provide notice of the modification to enrollees not later than 60 days prior to the date
78.20on which the modification will become effective.
78.21EFFECTIVE DATE.This section is effective the day following final enactment.

78.22    Sec. 91. Minnesota Statutes 2012, section 72A.20, subdivision 35, is amended to read:
78.23    Subd. 35. Determination of health plan policy limits. Any health plan under
78.24section 62A.011, subdivision 3, that includes a specific policy limit within its insurance
78.25policy, certificate, or subscriber agreement shall calculate the policy limit by using the
78.26amount actually paid on behalf of the insured, subscriber, or dependents for services
78.27covered under the policy, subscriber agreement, or certificate unless the amount paid is
78.28greater than the billed charge. This provision does not permit the application of a specific
78.29policy limit within a health plan where the limit is prohibited under the Affordable Care
78.30Act as defined in section 62A.011, subdivision 1a.
78.31EFFECTIVE DATE.This section is effective the day following final enactment.

78.32    Sec. 92. Minnesota Statutes 2012, section 471.61, subdivision 1a, is amended to read:
79.1    Subd. 1a. Dependents. Notwithstanding the provisions of Minnesota Statutes 1969,
79.2section 471.61, as amended by Laws 1971, chapter 451, section 1, the word "dependents" as
79.3used therein shall mean spouse and minor unmarried children under the age of 18 26 years
79.4and dependent students under the age of 25 years actually dependent upon the employee.
79.5EFFECTIVE DATE.This section is effective the day following final enactment.

79.6    Sec. 93. REPEALER.
79.7(a) Minnesota Statutes 2012, section 62E.02, subdivision 7, is repealed effective the
79.8day following final enactment.
79.9(b) Minnesota Statutes 2012, sections 62A.615; 62A.65, subdivision 6; 62E.16;
79.1062E.20; 62L.02, subdivisions 4, 18, 19, 23, and 24; 62L.05, subdivisions 1, 2, 3, 4, 4a,
79.115, 6, 7, 11, 12, and 13; 62L.081; 62L.10, subdivision 5; and 62Q.37, subdivision 5, are
79.12repealed effective January 1, 2014.

79.13ARTICLE 2
79.14MARKET RULES FOR AFFORDABLE CARE ACT

79.15    Section 1. Minnesota Statutes 2012, section 62D.124, subdivision 4, is amended to read:
79.16    Subd. 4. Application. (a) Subdivisions 1 and 2 do not apply if an enrollee is referred
79.17to a referral center for health care services.
79.18(b) Subdivision 1 does not apply:
79.19(1) if an enrollee has chosen a health plan with full knowledge that the health plan
79.20has no participating providers within 30 miles or 30 minutes of the enrollee's place of
79.21residence; or
79.22(2) to service areas approved before May 24, 1993.
79.23(c) Beginning for coverage effective on or after January 1, 2015, subdivisions 1 to 4
79.24shall only apply to individual or small group health plans that are grandfathered plans, as
79.25defined under section 62A.011, subdivision 1c.

79.26    Sec. 2. [62K.01] TITLE.
79.27This chapter may be cited as the "Minnesota Health Plan Market Rules."

79.28    Sec. 3. [62K.02] PURPOSE AND SCOPE.
79.29    Subdivision 1. Purpose. The market rules set forth in this chapter serve to clarify
79.30and provide guidance on the application of state law and certain requirements of the
79.31Affordable Care Act on all health carriers offering health plans in Minnesota, whether
80.1or not through the Minnesota Insurance Marketplace, to ensure fair competition for all
80.2health carriers in Minnesota, to minimize adverse selection, and to ensure that health
80.3plans are offered in a manner that protects consumers and promotes the provision of
80.4high-quality affordable health care, and improved health outcomes. This chapter contains
80.5the regulatory requirements as specified in section 62V.05, subdivision 5, paragraph (b),
80.6and shall fully satisfy the requirements of section 62V.05, subdivision 5, paragraph (b).
80.7    Subd. 2. Scope. (a) This chapter applies only to health plans offered in the
80.8individual market or the small group market.
80.9(b) This chapter applies to health carriers with respect to individual health plans and
80.10small group health plans, unless otherwise specified.
80.11(c) If a health carrier issues or renews individual or small group health plans in
80.12other states, this chapter applies only to health plans issued or renewed in this state to a
80.13Minnesota resident, or to cover a resident of the state, or issued or renewed to a small
80.14employer that is actively engaged in business in this state, unless otherwise specified.
80.15(d) This chapter does not apply to short-term coverage as defined in section 62A.65,
80.16subdivision 7, or grandfathered plan coverage as defined in section 62A.011, subdivision
80.171b.
80.18EFFECTIVE DATE.This section is effective for health plans that are offered, sold,
80.19issued or renewed on or after January 1, 2014.

80.20    Sec. 4. [62K.03] DEFINITIONS.
80.21    Subdivision 1. Applicability. For purposes of this chapter, the terms defined in this
80.22section have the meanings given.
80.23    Subd. 2. Affordable Care Act. "Affordable Care Act" means the federal Patient
80.24Protection and Affordable Care Act, Public Law 111-148, as amended, including the
80.25federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and
80.26any amendments, and any federal guidance or regulations issued under these acts.
80.27    Subd. 3. Dental plan. "Dental plan" means a dental plan as defined in section
80.2862Q.76, subdivision 3.
80.29    Subd. 4. Enrollee. "Enrollee" means a natural person covered by a health plan and
80.30includes an insured policyholder, subscriber, contract holder, member, covered person,
80.31or certificate holder.
80.32    Subd. 5. Health carrier. "Health carrier" means a health carrier as defined in
80.33section 62A.011, subdivision 2.
80.34    Subd. 6. Health plan. "Health plan" means a health plan as defined in section
80.3562A.011, subdivision 3.
81.1    Subd. 7. Individual health plan. "Individual health plan" means an individual
81.2health plan as defined in Minnesota Statutes, section 62A.011, subdivision 4.
81.3    Subd. 8. Limited-scope pediatric dental plan. "Limited-scope pediatric dental
81.4plan" means a dental plan meeting the requirements of section 9832(c)(2)(A) of the
81.5Internal Revenue Code of 1986, as amended, that provides only pediatric dental benefits
81.6meeting the requirements of the Affordable Care Act and is offered by a health carrier. A
81.7limited-scope pediatric dental plan includes a dental plan that is offered separately or in
81.8conjunction with an individual or small group health plan to individuals who have not
81.9attained the age of 19 years as of the beginning of the policy year or to a family.
81.10    Subd. 9. Minnesota Insurance Marketplace. "Minnesota Insurance Marketplace"
81.11means the Minnesota Insurance Marketplace as defined in section 62V.02.
81.12    Subd. 10. Preferred provider organization. "Preferred provider organization"
81.13means a health plan that provides discounts to enrollees or subscribers for services they
81.14receive from certain health care providers.
81.15    Subd. 11. Qualified health plan. "Qualified health plan" means a health plan
81.16that meets the definition in the Affordable Care Act and has been certified by the board
81.17of the Minnesota Insurance Marketplace in accordance with chapter 62V to be offered
81.18through the Minnesota Insurance Marketplace.
81.19    Subd. 12. Small group health plan. "Small group health plan" means a health plan
81.20issued by a health carrier to a small employer as defined in section 62L.02, subdivision 26.
81.21EFFECTIVE DATE.This section is effective for health plans that are offered, sold,
81.22issued, or renewed on or after January 1, 2014.

81.23    Sec. 5. [62K.04] MARKET RULES; VIOLATION.
81.24    Subdivision 1. Compliance. (a) A health carrier issuing an individual health plan to
81.25a Minnesota resident or a small group health plan to provide coverage to a small employer
81.26that is actively engaged in business in Minnesota shall meet all of the requirements set
81.27forth in this chapter. The failure to meet any of the requirements under this chapter
81.28constitutes a violation of section 72A.20.
81.29(b) The requirements of this chapter do not apply to short-term coverage as defined
81.30in section 62A.65, subdivision 7, or grandfathered plan coverage as defined in section
81.3162A.011, subdivision 1c.
81.32    Subd. 2. Penalties. In addition to any other penalties provided by the laws of this
81.33state or by federal law, a health carrier or any other person found to have violated any
81.34requirement of this chapter may be subject to the administrative procedures, enforcement
81.35actions, and penalties provided under section 45.027 and chapters 62D and 72A.
82.1EFFECTIVE DATE.This section is effective for health plans that are offered, sold,
82.2issued, or renewed on or after January 1, 2014.

82.3    Sec. 6. [62K.05] FEDERAL ACT; COMPLIANCE REQUIRED.
82.4A health carrier shall comply with all provisions of the Affordable Care Act to
82.5the extent that it imposes a requirement that applies in this state. Compliance with any
82.6provision of the Affordable Care Act is required as of the effective date established for
82.7that provision in the federal act, except as otherwise specifically stated earlier in state law.
82.8EFFECTIVE DATE.This section is effective for health plans that are offered, sold,
82.9issued, or renewed on or after January 1, 2014.

82.10    Sec. 7. [62K.06] METAL LEVEL MANDATORY OFFERINGS.
82.11    Subdivision 1. Identification. A health carrier that offers individual or small group
82.12health plans in Minnesota must provide documentation to the commissioner of commerce
82.13to justify actuarial value levels as specified in section 1302(d) of the Affordable Care Act
82.14for all individual and small group health plans offered inside and outside of the Minnesota
82.15Insurance Marketplace.
82.16    Subd. 2. Minimum levels. (a) A health carrier that offers a catastrophic plan or a
82.17bronze level health plan within a service area in either the individual or small group
82.18market must also offer a silver level and a gold level health plan in that market and
82.19within that service area.
82.20(b) A health carrier with less than five percent market share in the respective
82.21individual or small group market in Minnesota is exempt from paragraph (a), until January
82.221, 2017, unless the health carrier offers a qualified health plan through the Minnesota
82.23Insurance Marketplace. If the health carrier offers a qualified health plan through the
82.24Minnesota Insurance Marketplace, the health carrier must comply with paragraph (a).
82.25    Subd. 3. Minnesota Insurance Marketplace restriction. The Minnesota Insurance
82.26Marketplace may not, by contract or otherwise, mandate the types of health plans to be
82.27offered by a health carrier to individuals or small employers purchasing health plans outside
82.28of the Minnesota Insurance Marketplace. Solely for purposes of this subdivision, "health
82.29plan" includes coverage that is excluded under section 62A.011, subdivision 3, clause (6).
82.30    Subd. 4. Metal level defined. For purposes of this section, the metal levels and
82.31catastrophic plans are defined in section 1302(d) and (e) of the Affordable Care Act.
82.32    Subd. 5. Enforcement. The commissioner of commerce shall enforce this section.

82.33    Sec. 8. [62K.07] INFORMATION DISCLOSURES.
83.1(a) A health carrier offering individual or small group health plans must submit the
83.2following information in a format determined by the commissioner of commerce:
83.3(1) claims payment policies and practices;
83.4(2) periodic financial disclosures;
83.5(3) data on enrollment;
83.6(4) data on disenrollment;
83.7(5) data on the number of claims that are denied;
83.8(6) data on rating practices;
83.9(7) information on cost-sharing and payments with respect to out-of-network
83.10coverage; and
83.11(8) other information required by the secretary of the United States Department of
83.12Health and Human Services under the Affordable Care Act.
83.13(b) A health carrier offering an individual or small group health plan must comply
83.14with all information disclosure requirements of all applicable state and federal law,
83.15including the Affordable Care Act.
83.16(c) Except for qualified health plans sold on the Minnesota Insurance Marketplace,
83.17information reported under paragraph (a), clauses (3) and (4), is nonpublic data as defined
83.18under section 13.02, subdivision 9. Information reported under paragraph (a), clauses (1)
83.19through (8), must be reported by the Minnesota Insurance Marketplace for qualified health
83.20plans sold through the Minnesota Insurance Marketplace.
83.21(d) The commissioner of commerce shall enforce this section.

83.22    Sec. 9. [62K.08] MARKETING STANDARDS.
83.23    Subdivision 1. Marketing. (a) A health carrier offering individual or small group
83.24health plans must comply with all applicable provisions of the Affordable Care Act,
83.25including, but not limited to, the following:
83.26(1) compliance with all state laws pertaining to the marketing of individual or small
83.27group health plans; and
83.28(2) establishing marketing practices and benefit designs that will not have the effect of
83.29discouraging the enrollment of individuals with significant health needs in the health plan.
83.30(b) No marketing materials may lead consumers to believe that all health care needs
83.31will be covered.
83.32    Subd. 2. Enforcement. The commissioner of commerce shall enforce this section.
83.33EFFECTIVE DATE.This section is effective for health plans offered, sold, issued,
83.34or renewed on or after January 1, 2014.

84.1    Sec. 10. [62K.09] ACCREDITATION STANDARDS.
84.2    Subdivision 1. Accreditation; general. (a) A health carrier that offers any
84.3individual or small group health plans in Minnesota outside of the Minnesota Insurance
84.4Marketplace must be accredited in accordance with this subdivision. A health carrier
84.5must obtain accreditation through URAC, the National Committee for Quality Assurance
84.6(NCQA), or any entity recognized by the United States Department of Health and Human
84.7Services for accreditation of health insurance issuers or health plans by January 1,
84.82018. Proof of accreditation must be submitted to the commissioner of health in a form
84.9prescribed by the commissioner of health.
84.10(b) A health carrier that rents a provider network is exempt from this subdivision,
84.11unless it is part of a holding company as defined in section 60D.15 that in aggregate exceeds
84.12ten percent market share in either the individual or small group market in Minnesota.
84.13    Subd. 2. Accreditation; Minnesota Insurance Marketplace. (a) The Minnesota
84.14Insurance Marketplace shall require all health carriers offering a qualified health
84.15plan through the Minnesota Insurance Marketplace to obtain the appropriate level of
84.16accreditation no later than the third year after the first year the health carrier offers a
84.17qualified health plan through the Minnesota Insurance Marketplace. A health carrier
84.18must take the first step of the accreditation process during the first year in which it offers
84.19a qualified health plan. A health carrier that offers a qualified health plan on January 1,
84.202014, must obtain accreditation by the end of the 2016 plan year.
84.21(b) To the extent a health carrier cannot obtain accreditation due to low volume of
84.22enrollees, an exception to this accreditation criterion may be granted by the Minnesota
84.23Insurance Marketplace until such time as the health carrier has a sufficient volume of
84.24enrollees.
84.25    Subd. 3. Oversight. A health carrier shall comply with a request from the
84.26commissioner of health to confirm accreditation or progress toward accreditation.
84.27    Subd. 4. Enforcement. The commissioner of health shall enforce this section.

84.28    Sec. 11. [62K.10] GEOGRAPHIC ACCESSIBILITY; PROVIDER NETWORK
84.29ADEQUACY.
84.30    Subdivision 1. Applicability. (a) This section applies to all health carriers that either
84.31require an enrollee to use or that create incentives, including financial incentives, for an
84.32enrollee to use, health care providers that are managed, owned, under contract with, or
84.33employed by the health carrier. A health carrier that does not manage, own, or contract
84.34directly with providers in Minnesota is exempt from this section, unless it is part of a
85.1holding company as defined in section 60D.15 that in aggregate exceeds ten percent in
85.2either the individual or small group market in Minnesota.
85.3(b) Health carriers renting provider networks from other entities must submit the
85.4rental agreement or contract to the commissioner of health for approval. In reviewing the
85.5agreements or contracts, the commissioner shall review the agreement or contract to
85.6ensure that the entity contracting with health care providers accepts responsibility to meet
85.7the requirements in this section.
85.8    Subd. 2. Primary care; mental health services; general hospital services. The
85.9maximum travel distance or time shall be the lesser of 30 miles or 30 minutes to the
85.10nearest provider of each of the following services: primary care services, mental health
85.11services, and general hospital services.
85.12    Subd. 3. Other health services. The maximum travel distance or time shall be the
85.13lesser of 60 miles or 60 minutes to the nearest provider of specialty physician services,
85.14ancillary services, specialized hospital services, and all other health services not listed in
85.15subdivision 2.
85.16    Subd. 4. Network adequacy. Each designated provider network must include a
85.17sufficient number and type of providers, including providers that specialize in mental
85.18health and substance use disorder services, to ensure that covered services are available
85.19to all enrollees without unreasonable delay. In determining network adequacy, the
85.20commissioner of health shall consider availability of services, including the following:
85.21(1) primary care physician services are available and accessible 24 hours per day,
85.22seven days per week, within the network area;
85.23(2) a sufficient number of primary care physicians have hospital admitting privileges
85.24at one or more participating hospitals within the network area so that necessary admissions
85.25are made on a timely basis consistent with generally accepted practice parameters;
85.26(3) specialty physician service is available through the network or contract
85.27arrangement;
85.28(4) mental health and substance use disorder treatment providers are available and
85.29accessible through the network or contract arrangement;
85.30(5) to the extent that primary care services are provided through primary care
85.31providers other than physicians, and to the extent permitted under applicable scope of
85.32practice in state law for a given provider, these services shall be available and accessible;
85.33and
85.34(6) the network has available, either directly or through arrangements, appropriate
85.35and sufficient personnel, physical resources, and equipment to meet the projected needs of
85.36enrollees for covered health care services.
86.1    Subd. 5. Waiver. A health carrier or preferred provider organization may apply to
86.2the commissioner of health for a waiver of the requirements in subdivision 2 or 3 if it is
86.3unable to meet the statutory requirements. A waiver application must be submitted on a
86.4form provided by the commissioner and must:
86.5(1) demonstrate with specific data that the requirement of subdivision 2 or 3 is not
86.6feasible in a particular service area or part of a service area; and
86.7(2) include information as to the steps that were and will be taken to address the
86.8network inadequacy.
86.9The waiver shall automatically expire after four years. If a renewal of the waiver
86.10is sought, the commissioner of health shall take into consideration steps that have been
86.11taken to address network adequacy.
86.12    Subd. 6. Referral centers. Subdivisions 2 and 3 shall not apply if an enrollee
86.13is referred to a referral center for health care services. A referral center is a medical
86.14facility that provides highly specialized medical care, including but not limited to organ
86.15transplants. A health carrier or preferred provider organization may consider the volume
86.16of services provided annually, case mix, and severity adjusted mortality and morbidity
86.17rates in designating a referral center.
86.18    Subd. 7. Essential community providers. Each health carrier must comply with
86.19section 62Q.19.
86.20    Subd. 8. Enforcement. The commissioner of health shall enforce this section.

86.21    Sec. 12. [62K.11] BALANCE BILLING PROHIBITED.
86.22(a) A network provider is prohibited from billing an enrollee for any amount in
86.23excess of the allowable amount the health carrier has contracted for with the provider
86.24as total payment for the health care service. A network provider is permitted to bill an
86.25enrollee the approved co-payment, deductible, or coinsurance.
86.26(b) A network provider is permitted to bill an enrollee for services not covered by
86.27the enrollee's health plan as long as the enrollee agrees in writing in advance before the
86.28service is performed to pay for the noncovered service.
86.29EFFECTIVE DATE.This section is effective January 1, 2014.

86.30    Sec. 13. [62K.12] QUALITY ASSURANCE AND IMPROVEMENT.
86.31    Subdivision 1. General. (a) All health carriers offering an individual health plan or
86.32small group health plan must have a written internal quality assurance and improvement
86.33program that, at a minimum:
87.1(1) provides for ongoing evaluation of the quality of health care provided to its
87.2enrollees;
87.3(2) periodically reports the evaluation of the quality of health care to the health
87.4carrier's governing body;
87.5(3) follows policies and procedures for the selection and credentialing of network
87.6providers that is consistent with community standards;
87.7(4) conducts focused studies directed at problems, potential problems, or areas
87.8with potential for improvements in care;
87.9(5) conducts enrollee satisfaction surveys and monitors oral and written complaints
87.10submitted by enrollees or members; and
87.11(6) collects and reports Health Effectiveness Data and Information Set (HEDIS)
87.12measures and conducts other quality assessment and improvement activities as directed
87.13by the commissioner of health.
87.14    (b) The commissioner of health shall submit a report to the chairs and ranking
87.15minority members of senate and house of representatives committees with primary
87.16jurisdiction over commerce and health policy by February 15, 2015, with recommendations
87.17for specific quality assurance and improvement standards for all Minnesota health carriers.
87.18The recommended standards must not require duplicative data gathering, analysis, or
87.19reporting by health carriers.
87.20    Subd. 2. Exemption. A health carrier that rents a provider network is exempt from
87.21this section, unless it is part of a holding company as defined in section 60D.15 that in
87.22aggregate exceeds ten percent market share in either the individual or small group market
87.23in Minnesota.
87.24    Subd. 3. Waiver. A health carrier that has obtained accreditation through the URAC
87.25for network management; quality improvement; credentialing; member protection; and
87.26utilization management, or has achieved an excellent or commendable level ranking
87.27from the National Committee for Quality Assurance (NCQA), shall be deemed to meet
87.28the requirements of subdivision 1. Proof of accreditation must be submitted to the
87.29commissioner of health in a form prescribed by the commissioner. The commissioner may
87.30adopt rules to recognize similar accreditation standards from any entity recognized by
87.31the United States Department of Health and Human Services for accreditation of health
87.32insurance issuers or health plans.
87.33    Subd. 4. Enforcement. The commissioner of health shall enforce this section.

87.34    Sec. 14. [62K.13] SERVICE AREA REQUIREMENTS.
88.1(a) Any health carrier that offers an individual or small group health plan, must offer
88.2the health plan in a service area that is at least the entire geographic area of a county
88.3unless serving a smaller geographic area is necessary, nondiscriminatory, and in the best
88.4interest of enrollees. The service area for any individual or small group health plan must
88.5be established without regard to racial, ethnic, language, concentrated poverty, or health
88.6status-related factors, or other factors that exclude specific high-utilizing, high-cost, or
88.7medically underserved populations.
88.8(b) If a health carrier that offers an individual or small group health plan requests
88.9to serve less than the entire county, the request must be made to the commissioner of
88.10health on a form and manner determined by the commissioner and must provide specific
88.11data demonstrating that the service area is not discriminatory, is necessary, and is in the
88.12best interest of enrollees.
88.13(c) The commissioner of health shall enforce this section.

88.14    Sec. 15. [62K.14] LIMITED-SCOPE PEDIATRIC DENTAL PLANS.
88.15    (a) Limited-scope pediatric dental plans must be offered to the extent permitted
88.16under the Affordable Care Act: (1) on a guaranteed issue and guaranteed renewable basis;
88.17(2) with premiums rated on allowable rating factors used for health plans; and (3) without
88.18any exclusions or limitations based on preexisting conditions.
88.19    (b) Notwithstanding paragraph (a), a health carrier may discontinue a limited scope
88.20pediatric dental plan if the health carrier provides written notice to enrollees at least 90
88.21calendar days before coverage is to be discontinued that the particular plan is being
88.22discontinued and the health carrier offers enrollees other dental plan options that are the
88.23same or substantially similar to the dental plan being discontinued in terms of premiums,
88.24benefits, cost-sharing requirements, and network adequacy.
88.25(c) Limited-scope pediatric dental plans must ensure primary care dental services
88.26are available within 60 miles or 60 minutes' travel time.
88.27(d) If a stand-alone dental plan as defined under the Affordable Care Act or a
88.28limited-scope pediatric dental plan is offered, either separately or in conjunction with
88.29a health plan offered to individuals or small employers, the health plan shall not be
88.30considered in noncompliance with the requirements of the essential benefit package in the
88.31Affordable Care Act because the health plan does not offer coverage of pediatric dental
88.32benefits if these benefits are covered through the stand-alone or limited-scope pediatric
88.33dental plan, to the extent permitted under the Affordable Care Act.
88.34(e) Health carriers offering limited-scope pediatric dental plans must comply with
88.35this section and sections 62K.07, 62K.08, 62K.13, and 62K.15.
89.1    (f) The commissioner of commerce shall enforce paragraphs (a) and (b). Any limited
89.2scope pediatric dental plan that is to be offered to replace a discontinued dental plan under
89.3paragraph (b) must be approved by the commissioner of commerce in terms of cost and
89.4benefit similarity, and the commissioner of health in terms of network adequacy similarity.
89.5The commissioner of health shall enforce paragraph (c).
89.6EFFECTIVE DATE.This section is effective for health plans and dental plans that
89.7are offered, sold, issued, or renewed on or after January 1, 2014, with the exception of
89.8paragraphs (a) and (b), which are effective for health plans and dental plans that are
89.9offered, sold, issued, or renewed on or after January 1, 2015.

89.10    Sec. 16. [62K.15] ANNUAL OPEN ENROLLMENT PERIODS.
89.11(a) Health carriers offering individual health plans must limit annual enrollment in
89.12the individual market to the annual open enrollment periods for the Minnesota Insurance
89.13Marketplace. Nothing in this section limits the application of special or limited open
89.14enrollment periods as defined under the Affordable Care Act.
89.15(b) Health carriers offering individual health plans must inform all applicants at the
89.16time of application and enrollees at least annually of the open and special enrollment
89.17periods as defined under the Affordable Care Act.
89.18(c) The commissioner of commerce shall enforce this section.

89.19    Sec. 17. Minnesota Statutes 2012, section 62Q.19, subdivision 1, is amended to read:
89.20    Subdivision 1. Designation. (a) The commissioner shall designate essential
89.21community providers. The criteria for essential community provider designation shall be
89.22the following:
89.23(1) a demonstrated ability to integrate applicable supportive and stabilizing services
89.24with medical care for uninsured persons and high-risk and special needs populations,
89.25underserved, and other special needs populations; and
89.26(2) a commitment to serve low-income and underserved populations by meeting the
89.27following requirements:
89.28(i) has nonprofit status in accordance with chapter 317A;
89.29(ii) has tax-exempt status in accordance with the Internal Revenue Service Code,
89.30section 501(c)(3);
89.31(iii) charges for services on a sliding fee schedule based on current poverty income
89.32guidelines; and
89.33(iv) does not restrict access or services because of a client's financial limitation;
90.1(3) status as a local government unit as defined in section 62D.02, subdivision 11, a
90.2hospital district created or reorganized under sections 447.31 to 447.37, an Indian tribal
90.3government, an Indian health service unit, or a community health board as defined in
90.4chapter 145A;
90.5(4) a former state hospital that specializes in the treatment of cerebral palsy, spina
90.6bifida, epilepsy, closed head injuries, specialized orthopedic problems, and other disabling
90.7conditions;
90.8(5) a sole community hospital. For these rural hospitals, the essential community
90.9provider designation applies to all health services provided, including both inpatient and
90.10outpatient services. For purposes of this section, "sole community hospital" means a
90.11rural hospital that:
90.12(i) is eligible to be classified as a sole community hospital according to Code
90.13of Federal Regulations, title 42, section 412.92, or is located in a community with a
90.14population of less than 5,000 and located more than 25 miles from a like hospital currently
90.15providing acute short-term services;
90.16(ii) has experienced net operating income losses in two of the previous three
90.17most recent consecutive hospital fiscal years for which audited financial information is
90.18available; and
90.19(iii) consists of 40 or fewer licensed beds; or
90.20(6) a birth center licensed under section 144.615.; or
90.21(7) a hospital and affiliated specialty clinics that predominately serve patients who
90.22are under 21 years of age, and meet the following criteria: (i) provides intensive specialty
90.23pediatric services that are routinely provided in fewer than five hospitals in the state; and
90.24(ii) serves children from at least half the counties in the state.
90.25(b) Prior to designation, the commissioner shall publish the names of all applicants
90.26in the State Register. The public shall have 30 days from the date of publication to submit
90.27written comments to the commissioner on the application. No designation shall be made
90.28by the commissioner until the 30-day period has expired.
90.29(c) The commissioner may designate an eligible provider as an essential community
90.30provider for all the services offered by that provider or for specific services designated by
90.31the commissioner.
90.32(d) For the purpose of this subdivision, supportive and stabilizing services include at
90.33a minimum, transportation, child care, cultural, and linguistic services where appropriate.
90.34EFFECTIVE DATE.This section is effective for health plans offered, sold, issued,
90.35or renewed on or after January 1, 2014.

91.1    Sec. 18. EFFECTIVE DATE.
91.2Sections 1 to 17 are effective for health plans offered, sold, issued, or renewed on or
91.3after January 1, 2015, unless otherwise specified.