HF 929

as introduced - 80th Legislature (1997 - 1998) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to insurance; creating a statewide health 
  1.3             care consumer assistance program; prohibiting 
  1.4             contracts that restrict communication between 
  1.5             providers and their patients; requiring disclosure of 
  1.6             health care provider financial incentives; requiring 
  1.7             health plan companies to provide continuity of care 
  1.8             and access to specialty care for certain enrollees; 
  1.9             prohibiting certain exclusive arrangements; 
  1.10            appropriating money; amending Minnesota Statutes 1996, 
  1.11            section 181.932, subdivision 1; proposing coding for 
  1.12            new law in Minnesota Statutes, chapters 62J; and 62Q; 
  1.13            repealing Minnesota Statutes 1996, sections 62Q.105, 
  1.14            subdivisions 2, 3, 4, and 8; and 62Q.11.  
  1.15  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.16     Section 1.  [LEGISLATIVE INTENT.] 
  1.17     It is the intent of the legislature in this Patient 
  1.18  Protection Act to establish additional state consumer 
  1.19  protections and assistance relating to the coverage for and 
  1.20  delivery of health care treatment and services that will 
  1.21  supplement and complement existing laws and regulations and 
  1.22  further ensure that no patient receiving services or treatment 
  1.23  within Minnesota will be harmed by inappropriate health care 
  1.24  practices or treatment, and to provide improved assistance to 
  1.25  consumers and patients who have questions or problems relating 
  1.26  to their health care coverage or treatment. 
  1.27     Sec. 2.  [62J.70] [DEFINITIONS.] 
  1.28     Subdivision 1.  [APPLICABILITY.] For purposes of sections 
  1.29  62J.70 to 62J.72, the terms defined in this subdivision have the 
  1.30  meanings given them. 
  2.1      Subd. 2.  [HEALTH CARE PROVIDER OR PROVIDER.] "Health care 
  2.2   provider" or "provider" means: 
  2.3      (1) a physician, nurse, or other provider as defined under 
  2.4   section 62J.03; 
  2.5      (2) a hospital as defined under section 144.696, 
  2.6   subdivision 3; 
  2.7      (3) an individual or entity that provides health care 
  2.8   coverage or services under the medical assistance, general 
  2.9   assistance medical care, MinnesotaCare, or state employee group 
  2.10  insurance program; and 
  2.11     (4) an association, partnership, corporation, limited 
  2.12  liability corporation, or other organization of persons or 
  2.13  entities described in clause (1) or (2) organized for the 
  2.14  purposes of providing, arranging, or administering health care 
  2.15  services or treatment.  
  2.16     Subd. 3.  [PATIENT.] "Patient" includes a former, current, 
  2.17  or prospective patient of a health care provider.  
  2.18     Subd. 4.  [HEALTH PLAN COMPANY.] "Health plan company" 
  2.19  includes:  any association, partnership, corporation, joint 
  2.20  venture, cooperative, limited liability corporation, or other 
  2.21  organization of persons or entities, including counties, 
  2.22  described in subdivision 2, clauses (1) and (2), organized for 
  2.23  the purposes of providing, arranging, or administering health 
  2.24  care services or treatment.  It includes, but is not limited to, 
  2.25  a third-party administrator of a benefits plan that pays 
  2.26  hospital and medical expense benefits for covered services and 
  2.27  is delivered or issued for delivery in this state by or through 
  2.28  a carrier or any other entity and a managed care plan that 
  2.29  integrates the financing and delivery of appropriate health care 
  2.30  services to covered individuals. 
  2.31     Subd. 5.  [MEDICALLY URGENT COMPLAINT.] "Medically urgent 
  2.32  complaint" involves medically necessary care which is needed as 
  2.33  soon as possible, usually within 24 hours, to protect the health 
  2.34  of the patient.  Medically urgent complaints include, but are 
  2.35  not limited to, medical care that meets the definition of 
  2.36  emergency medical condition set forth in section 62Q.55.  
  3.1      Subd. 6.  [ENROLLEE.] "Enrollee" means an individual 
  3.2   enrolled with a health plan company with regard to coverage. 
  3.3      Subd. 7.  [SUBSTANTIAL FINANCIAL RISK.] Substantial 
  3.4   financial risk is transferred when a plan places a physician, 
  3.5   physician group, or health care provider at risk for more than 
  3.6   25 percent of potential payments.  "Potential payments" means 
  3.7   the maximum anticipated total payments that could be received if 
  3.8   use or costs of referral services were low enough.  "Payments" 
  3.9   include amounts paid to a physician or physician group for 
  3.10  services and administration, and amounts based on use and costs 
  3.11  of referral services.  Potential payments do not include bonuses 
  3.12  and other compensation that are not based on referral levels, 
  3.13  such as bonuses based solely on quality of care, patient 
  3.14  satisfaction, and participation on committees.  
  3.15     Subd. 8.  [NONAPPLICABILITY.] Sections 62J.70 to 62J.72 do 
  3.16  not apply to a trade association, membership association of 
  3.17  health care professionals, or other organization that does not 
  3.18  directly provide, arrange, or administer health care services or 
  3.19  treatment.  
  3.20     Sec. 3.  [62J.71] [PROHIBITED PROVIDER CONTRACTS.] 
  3.21     Subdivision 1.  [AGREEMENTS AND DIRECTIVES PROHIBITED.] The 
  3.22  following types of agreements or directives are contrary to 
  3.23  state public policy, are prohibited under this section, and are 
  3.24  null and void: 
  3.25     (1) any oral or written agreement or directive that 
  3.26  prohibits a health care provider from communicating with a 
  3.27  patient with respect to the patient's health status, health 
  3.28  care, or treatment options, if the health care provider is 
  3.29  acting in good faith and within the provider's scope of practice 
  3.30  as defined by law; 
  3.31     (2) any oral or written agreement or directive that 
  3.32  prohibits a health care provider from disclosing accurate 
  3.33  information about whether services or treatment will be paid for 
  3.34  by a patient's health insurance, health coverage plan, or other 
  3.35  third-party payment arrangement; and 
  3.36     (3) any oral or written agreement or directive that 
  4.1   prohibits a health care provider from informing a patient about 
  4.2   the nature of the reimbursement methodology used by a health 
  4.3   plan company to pay the provider, including any incentives or 
  4.4   penalties intended to encourage providers to withhold services 
  4.5   or minimize or avoid referrals to specialists. 
  4.6      Subd. 2.  [PERSONS AND ENTITIES AFFECTED.] The following 
  4.7   persons and entities shall not enter into any oral or written 
  4.8   agreement, or issue or comply with any directive, that is 
  4.9   prohibited under this section: 
  4.10     (1) a health plan company; 
  4.11     (2) a health care network cooperative as defined under 
  4.12  section 62R.04, subdivision 3; 
  4.13     (3) a health care provider as defined in section 62J.70, 
  4.14  subdivision 2; or 
  4.15     (4) any other individual or entity that delivers, arranges, 
  4.16  or administers health care services or treatment or administers 
  4.17  a health coverage plan.  
  4.18     Subd. 3.  [RETALIATION PROHIBITED.] No person, health plan 
  4.19  company, or other organization may take retaliatory action 
  4.20  against a health care provider solely on the grounds that the 
  4.21  provider: 
  4.22     (1) refused to enter into an agreement or to follow a 
  4.23  directive that is prohibited under this section; 
  4.24     (2) disclosed accurate information about whether a health 
  4.25  care service or treatment is covered by a patient's health 
  4.26  insurance or health coverage plan; 
  4.27     (3) expressed disagreement with a health plan's decision to 
  4.28  deny or limit services to a patient; 
  4.29     (4) assisted a patient in seeking reconsideration of a 
  4.30  health plan decision to deny or limit services; or 
  4.31     (5) offered a personal recommendation to a patient 
  4.32  regarding the selection of a health plan based on the provider's 
  4.33  personal knowledge of the health needs of a patient. 
  4.34     Sec. 4.  [62J.72] [DISCLOSURE OF HEALTH CARE PROVIDER 
  4.35  INFORMATION.] 
  4.36     Subdivision 1.  [WRITTEN DISCLOSURE.] A health plan 
  5.1   company, a health care network cooperative as defined under 
  5.2   section 62R.04, subdivision 3, a health care provider as defined 
  5.3   under section 62J.70, subdivision 2, and any other individual or 
  5.4   entity that administers a health coverage plan shall, prior to 
  5.5   enrollment and thereafter upon request, supply to its current 
  5.6   and prospective enrollees, subscribers, insureds, or patients 
  5.7   written disclosure information, which may be incorporated into 
  5.8   the member handbook, subscriber contract, direct marketing 
  5.9   materials, or certificate, containing at least the following 
  5.10  information: 
  5.11     (1) a concise written description of any provider payment 
  5.12  plan, including any incentive plan applicable to the enrollment; 
  5.13     (2) a written description of any penalty or incurred 
  5.14  liability for the provider that is utilized to encourage a 
  5.15  provider to withhold services, or to minimize or avoid referrals 
  5.16  to specialists; 
  5.17     (3) a written description of any incentive the provider has 
  5.18  not to provide care.  This includes any compensation arrangement 
  5.19  that is dependent on limiting health care coverage or health 
  5.20  care services, such as requiring a provider to meet a specific 
  5.21  number or a targeted average, or setting a maximum duration for 
  5.22  patient services; and 
  5.23     (4) a written description of any incentive plan that 
  5.24  involves the transfer of substantial financial risk, as defined 
  5.25  in section 62J.70, subdivision 7, to a health care provider. 
  5.26     Subd. 2.  [INFORMATION ON PATIENTS' MEDICAL BILLS.] A 
  5.27  health plan company and health care provider subject to this act 
  5.28  shall provide patients with a copy of an itemized and 
  5.29  intelligible bill whenever the patient is responsible for paying 
  5.30  any portion of that bill.  The bills must contain descriptive 
  5.31  language sufficient to be understood by the average enrollee. 
  5.32     Subd. 3.  [INFORMATION ON CREDENTIALS OF PROVIDERS.] Any 
  5.33  health care provider who is licensed, credentialed, or 
  5.34  registered by a health-related licensing board as defined under 
  5.35  section 214.01, subdivision 2, must wear a name tag that 
  5.36  indicates by words, letters, abbreviations, or insignia the 
  6.1   profession or occupation of the individual.  The name tag must 
  6.2   be worn whenever the health care provider is rendering health 
  6.3   services to a patient, unless wearing the name tag would create 
  6.4   a safety or health risk to the patient. 
  6.5      Subd. 4.  [INFORMATION ON SURVEYS.] Each health care 
  6.6   provider shall, upon request, provide a summary of any surveys 
  6.7   or results of external surveys it participated in, including, 
  6.8   but not limited to, patient satisfaction and patient access 
  6.9   surveys. 
  6.10     Subd. 5.  [NONAPPLICABILITY.] Health care providers as 
  6.11  defined in section 62J.70, subdivision 2, clause (1), need not 
  6.12  individually provide information required under this section if 
  6.13  it has been provided by another entity that is subject to this 
  6.14  section. 
  6.15     Sec. 5.  [62J.73] [HEALTH CARE CONSUMER ASSISTANCE 
  6.16  PROGRAM.] 
  6.17     Subdivision 1.  [ESTABLISHMENT.] The commissioners of 
  6.18  health and commerce, in consultation with the commissioners of 
  6.19  human services and employee relations, shall establish a 
  6.20  statewide program to provide assistance to consumers, patients, 
  6.21  or enrollees with complaints or problems relating to their 
  6.22  health care or health coverage plan.  The program shall include 
  6.23  a statewide toll-free telephone number.  
  6.24     Subd. 2.  [SELECTION CRITERIA.] The commissioner of 
  6.25  administration shall contract with an agency, organization, or 
  6.26  consortium of organizations to operate the health care consumer 
  6.27  assistance program.  The commissioner shall not contract with an 
  6.28  agency, organization, or consortium that:  
  6.29     (1) has a direct involvement in the licensing, 
  6.30  certification, or accreditation of a health care facility, 
  6.31  health plan company, or health care provider; 
  6.32     (2) has a direct ownership or financial interest in a 
  6.33  health care facility, health plan company, or in providing, 
  6.34  arranging, or administering health care services or treatment; 
  6.35  or 
  6.36     (3) is employed by or is under contract to provide 
  7.1   management services to a health care facility, health plan 
  7.2   company, or an entity that provides, arranges, or administers 
  7.3   health care services or treatment.  
  7.4      Subd. 3.  [FUNCTIONS.] The health care consumer assistance 
  7.5   program shall provide assistance to all health care consumers: 
  7.6      (1) by educating and training consumers about their health 
  7.7   care program or health coverage plan; 
  7.8      (2) in obtaining appropriate referrals and information to 
  7.9   enable consumers to assert their rights as patients; 
  7.10     (3) in obtaining information and outcomes data on health 
  7.11  plan company and health care provider performances; 
  7.12     (4) by identifying and monitoring trends in patient 
  7.13  complaints about health care coverage and services; 
  7.14     (5) by providing patients referrals to another state 
  7.15  consumer assistance, ombudsman, or advocacy service whenever 
  7.16  possible; and 
  7.17     (6) by assisting patients in understanding their 
  7.18  contractual and legal rights, including the rights under the 
  7.19  dispute resolution process.  This assistance can include 
  7.20  advocacy for patients in administration proceedings or other 
  7.21  formal dispute resolution processes, where appropriate.  
  7.22     Subd. 4.  [CONSUMER ADVISORY BOARD.] (a) The consumer 
  7.23  advisory board shall advise on the design of the request for 
  7.24  proposal described in subdivision 2 of this section; make 
  7.25  recommendations on the implementation and oversight of the 
  7.26  health care consumer assistance program, including future 
  7.27  funding levels and mechanisms; and report annually to the 
  7.28  legislature on trends in patient complaints and resolution of 
  7.29  those complaints. 
  7.30     (b) The board shall consist of 16 consumers as specified in 
  7.31  this subdivision.  All members of the board must be public, 
  7.32  consumer members who: 
  7.33     (1) do not have and never had a material interest in either 
  7.34  the provision of health care services or in an activity directly 
  7.35  related to the provision of health care services, such as health 
  7.36  insurance sales or health plan administration; 
  8.1      (2) are not currently responsible for or directly involved 
  8.2   in the purchasing of health insurance for a business or 
  8.3   organization; and 
  8.4      (3) are not registered lobbyists.  
  8.5      The governor, the speaker of the house, and the senate 
  8.6   majority leader shall each appoint two members.  The Asian 
  8.7   Pacific Minnesotans council, council on Black Minnesotans, 
  8.8   Spanish-speaking affairs council, and mid-Minnesota legal 
  8.9   assistance shall each appoint one member.  Health care campaign 
  8.10  of Minnesota, Minnesotans for affordable health care, and 
  8.11  consortium for citizens with disabilities shall each appoint two 
  8.12  members. 
  8.13     Subd. 5.  [IMMUNITY.] Employees, or persons employed by an 
  8.14  entity contracting with, the health care consumer assistance 
  8.15  program are immune from liability to the same extent as an 
  8.16  ombudsman under section 245.96. 
  8.17     Sec. 6.  [62J.74] [CERTIFICATE OF COMPLIANCE.] 
  8.18     Subdivision 1.  [SCOPE OF APPLICATION.] No department or 
  8.19  agency of the state shall accept any bid or proposal for a 
  8.20  contract or agreement or execute any contract or agreement for 
  8.21  provision of health care coverage or services under medical 
  8.22  assistance, general assistance medical care, state employee 
  8.23  benefit plans, or MinnesotaCare program in excess of $50,000, 
  8.24  unless the health plan company has received a certificate of 
  8.25  compliance issued by the commissioner of health.  The 
  8.26  certificate of compliance signifies that the health plan company 
  8.27  has the contracts and arrangements in place in all health plans 
  8.28  and contracts it administers or participates in to comply with 
  8.29  the patient protection act including the requirements in 
  8.30  sections 62J.70 to 62J.72 and 62Q.53 to 62Q.62.  The health plan 
  8.31  company may apply for a certificate of compliance by presenting 
  8.32  an adequate patient protection plan which addresses matters 
  8.33  raised in this act or by submitting the underlying contracts and 
  8.34  disclosures for the commissioner of health to review.  Receipt 
  8.35  of a certificate of compliance issued by the commissioner of 
  8.36  health shall signify that the health plan company has a plan 
  9.1   that has been approved by the commissioner of health.  A 
  9.2   certificate shall be valid for two years. 
  9.3      Subd. 2.  [REVOCATION OF CERTIFICATE.] Certificates of 
  9.4   compliance may be suspended or revoked by the commissioner of 
  9.5   health if the holder of a certificate has not made a good faith 
  9.6   effort to implement provisions of this act. 
  9.7      Subd. 3.  [REVOCATION OF CONTRACT.] A contract awarded by 
  9.8   the department or agency of the state may be terminated or 
  9.9   abridged by the department or agency because of suspension or 
  9.10  revocation of a certificate based upon a contract or failure to 
  9.11  implement or make a good faith effort to implement the 
  9.12  provisions of this patient protection act.  If a contract is 
  9.13  awarded to a person who does not have a contract compliance 
  9.14  certificate required under this subdivision, the commissioner of 
  9.15  health may void the contract on behalf of the state. 
  9.16     Subd. 4.  [RULES.] The commissioner of health shall adopt 
  9.17  rules to implement this section by specifying the criteria used 
  9.18  to review compliance with this act. 
  9.19     Sec. 7.  [62J.75] [SEVERABILITY.] 
  9.20     If any of a section, subdivision, clause, phrase, or work 
  9.21  of this act is for any reason held to be unconstitutional or in 
  9.22  violation of federal law, the decision shall not affect the 
  9.23  validity of the remaining portions of this act.  To the extent 
  9.24  allowed by federal law, this act shall be interpreted and 
  9.25  construed to fulfill the intent of the legislature to establish 
  9.26  universal patient protections and consumer assistance that will 
  9.27  protect and assist any Minnesota patient or consumer without 
  9.28  regard to the nature of the individual's health status or 
  9.29  condition, need for care or treatment, type of health care 
  9.30  provider used, health coverage, or status as a recipient of 
  9.31  public assistance. 
  9.32     Sec. 8.  [62J.76] [ENFORCEMENT.] 
  9.33     Subdivision 1.  [AUTHORITY.] The commissioners of health 
  9.34  and commerce shall each periodically review contracts and 
  9.35  arrangements among health care providing entities and health 
  9.36  plan companies they regulate to determine compliance with 
 10.1   sections 62J.70 to 62J.76.  Any person may submit a contract or 
 10.2   arrangement to the relevant commissioner for review if the 
 10.3   person believes sections 62J.70 to 62J.76 have been violated.  
 10.4   Any provision of a contract or arrangement found by the relevant 
 10.5   commissioner to violate this section is null and void, and the 
 10.6   relevant commissioner may assess civil penalties against the 
 10.7   health plan company in an amount not to exceed $2,500 for each 
 10.8   day the contract or arrangement is in effect, and may use the 
 10.9   enforcement procedures otherwise available to the commissioner. 
 10.10     Subd. 2.  [ASSISTANCE TO LICENSING BOARDS.] A 
 10.11  health-related licensing board as defined under section 214.01, 
 10.12  subdivision 2, may submit a contract or arrangement to the 
 10.13  relevant commissioner for review if the board believes sections 
 10.14  62J.70 to 62J.76 have been violated.  If the commissioner 
 10.15  determines that any provision of a contract or arrangement 
 10.16  violates those sections, the board may take disciplinary action 
 10.17  against any person who is licensed or regulated by the board who 
 10.18  entered into the contract arrangement. 
 10.19     Sec. 9.  [62J.77] [NONPREEMPTION.] 
 10.20     Nothing in this act preempts or replaces requirements 
 10.21  related to patient protections that are more protective of 
 10.22  patient rights than the requirements established in this act. 
 10.23     Sec. 10.  [62Q.53] [COMPLAINT AND APPEAL MECHANISMS.] 
 10.24     Subdivision 1.  [PURPOSE.] A health plan company shall 
 10.25  establish and administer an internal appeal procedure.  Pursuant 
 10.26  to this procedure, an enrollee shall be entitled to seek a 
 10.27  review of any determination by the health plan company that 
 10.28  relates to health care quality, services, treatment, or access 
 10.29  to needed services. 
 10.30     Subd. 2.  [FILING.] A health plan company subject to this 
 10.31  chapter shall provide written notice of its internal appeal 
 10.32  procedure to its enrollees in its certificate of coverage and 
 10.33  open enrollment materials.  The health plan company also shall 
 10.34  provide enrollees with written notice of the appeal procedure 
 10.35  any time access to a referral is ended or denied or a 
 10.36  determination is made that a requested benefit is not covered 
 11.1   under the contract.  The notice shall describe: 
 11.2      (1) the process for filing a complaint and appeal from the 
 11.3   initial resolution of the complaint; 
 11.4      (2) the time frames within which determinations of 
 11.5   complaints and appeals must be made; 
 11.6      (3) the right of the enrollee to file a separate complaint 
 11.7   with the Minnesota department of health or commerce; 
 11.8      (4) the ability of the enrollee to request mediation and 
 11.9   arbitration under section 62Q.54 at any time during the appeal 
 11.10  process; and 
 11.11     (5) the availability of referrals and assistance for health 
 11.12  care consumers through the statewide health care consumer 
 11.13  assistance program. 
 11.14     Subd. 3.  [ACCESSIBILITY.] The health plan company shall 
 11.15  assure that the complaint and appeal procedure is accessible to 
 11.16  those who do not speak English and shall provide a mechanism in 
 11.17  which an oral complaint may be initiated by calling a toll-free 
 11.18  telephone number, which will be available no less than 40 hours 
 11.19  per week during normal business hours and, in the case of 
 11.20  medically urgent appeals, on a 24-hour-a-day, 7-days-a-week 
 11.21  basis. 
 11.22     Subd. 4.  [TIMELINES.] All complaints must be resolved in 
 11.23  an expeditious manner and in any event the health plan company 
 11.24  shall make a determination and provide notice no more than: 
 11.25     (1) 48 hours after receipt of a medically urgent complaint; 
 11.26     (2) 15 days after receipt of the complaint in the case of 
 11.27  requests for referrals to specialists; and 
 11.28     (3) 30 days after receipt of the complaint in all other 
 11.29  instances. 
 11.30     Subd. 5.  [APPEALS FROM INITIAL DENIAL.] Individuals 
 11.31  reviewing the complaints must include health care professionals 
 11.32  who are licensed, trained, and practicing in the area involved 
 11.33  in the complaint.  If a decision by a health plan company 
 11.34  regarding an initial complaint is partially or wholly adverse to 
 11.35  the enrollee, the health plan company shall provide detailed 
 11.36  written reasons for the denial and the information in 
 12.1   subdivision 2.  The person or persons conducting the internal 
 12.2   appeal from a denial of a complaint must have the authority to 
 12.3   resolve the appeal and must not be the person or persons who 
 12.4   decided the enrollee's original complaint.  The determination of 
 12.5   the appeal and notice to the enrollee shall occur no more than: 
 12.6      (1) 48 hours after the appeal is requested when a medically 
 12.7   urgent complaint is involved; 
 12.8      (2) 15 business days after the appeal is requested in the 
 12.9   case of requests for referrals to specialist care; and 
 12.10     (3) 30 days after receipt of the appeal in all other 
 12.11  instances. 
 12.12     If the internal appeal is partially or wholly adverse to 
 12.13  the enrollee, the health plan company shall provide the enrollee 
 12.14  with the basis for the determination and, in the case of 
 12.15  clinical determinations, the credentials of the organization's 
 12.16  personnel who reviewed the appeal, and the information specified 
 12.17  in subdivision 2. 
 12.18     Sec. 11.  [62Q.54] [IMPARTIAL ALTERNATIVE DISPUTE 
 12.19  RESOLUTION.] 
 12.20     Subdivision 1.  [GENERAL.] Mediation and arbitration 
 12.21  services shall be provided by a contractor selected through the 
 12.22  process set out in subdivision 2.  The health plan company shall 
 12.23  participate in alternative dispute resolution pursuant to this 
 12.24  subdivision if the right to mediation and arbitration is invoked 
 12.25  by the enrollee.  Mediation and arbitration services must be 
 12.26  accessible to those who do not speak English.  The nature of 
 12.27  mediation and arbitration, including the nature and impact of 
 12.28  agreeing to binding arbitration, must be made clear by the 
 12.29  contractor to the enrollees and the health plan company.  An 
 12.30  arbitration must be handled on an expedited basis, in any event 
 12.31  no longer than 30 days after receipt of the request for 
 12.32  arbitration, if either a medically urgent complaint is involved 
 12.33  or a delay would significantly increase the risk to the 
 12.34  enrollee's health.  The enrollee may drop a complaint at any 
 12.35  point in this alternative dispute resolution process until and 
 12.36  unless the enrollee initiates binding arbitration.  Only the 
 13.1   enrollee can initiate binding arbitration.  The health plan 
 13.2   company must develop a procedure that allows enrollees with 
 13.3   medically urgent complaints to request a bypass of the internal 
 13.4   complaint process and proceed immediately to arbitration.  A 
 13.5   judgment upon an award rendered by the arbitrator may be entered 
 13.6   in any court having jurisdiction under sections 572.16 and 
 13.7   572.21. 
 13.8      Subd. 2.  [SELECTION PROCESS.] The commissioner of 
 13.9   administration, in consultation with the commissioners of health 
 13.10  and commerce, shall contract with an agency, organization or 
 13.11  consortium of organizations with expertise in the law and in 
 13.12  alternative dispute resolution to operate the alternative 
 13.13  dispute resolution program.  The commissioner shall not contract 
 13.14  with an agency or organization that: 
 13.15     (1) has a direct involvement in the licensing, 
 13.16  certification, or accreditation of a health care facility, 
 13.17  health plan company, or health care provider; 
 13.18     (2) has a direct ownership or financial interest in a 
 13.19  health care facility, health plan company, or in providing, 
 13.20  arranging, or administering health care services or treatment; 
 13.21  or 
 13.22     (3) is employed by or is under contract to provide 
 13.23  management services to a health care facility, health plan 
 13.24  company, or an entity that provides, arranges, or administers 
 13.25  health care services or treatment. 
 13.26     Subd. 3.  [STAY.] Procedures under this alternative dispute 
 13.27  resolution process are stayed when the enrollee files suit 
 13.28  against the health plan company or when the enrollee makes the 
 13.29  health plan company a party to the enrollee's suit against 
 13.30  another party concerning the facts giving rise to the enrollee 
 13.31  complaint.  Upon decision on the merits, the enrollee is deemed 
 13.32  to have waived the remedies under this section.  If an 
 13.33  enrollee's case is dismissed for reasons other than on the 
 13.34  merits or if the enrollee and the health plan company agree, the 
 13.35  enrollee may access the procedures under this section. 
 13.36     Subd. 4.  [COSTS.] Access to the appeals system, mediation, 
 14.1   and arbitration must be at no cost to the enrollee, except that 
 14.2   the health plan company is not responsible for any attorney's 
 14.3   fees incurred by the enrollee.  Mediation and arbitration costs 
 14.4   must be borne by the health plan company. 
 14.5      Sec. 12.  [62Q.55] [EMERGENCY SERVICES.] 
 14.6      (a) Enrollees have the right to available and accessible 
 14.7   services, including emergency services, 24 hours a day and seven 
 14.8   days a week.  The health plan company shall inform its enrollees 
 14.9   how to obtain emergency care and shall make available a 
 14.10  toll-free number, which is answered 24 hours a day, to answer 
 14.11  questions about emergency services and to receive reports and 
 14.12  provide authorizations, where appropriate, for treatment of 
 14.13  emergency medical conditions.  Emergency services shall be 
 14.14  covered whether provided by participating or nonparticipating 
 14.15  providers and whether provided within or outside the health plan 
 14.16  company's service area.  In determining whether care is 
 14.17  reimbursable as an emergency medical condition, the health plan 
 14.18  company shall take the following factors into consideration: 
 14.19     (1) a reasonable layperson's belief that the circumstances 
 14.20  required immediate medical care that could not wait until the 
 14.21  next working day or next available clinic appointment; 
 14.22     (2) the time of day and day of the week the care was 
 14.23  provided; 
 14.24     (3) the presenting symptoms, including, but not limited to, 
 14.25  severe pain, to ensure that the decision to reimburse the 
 14.26  emergency care is not made solely on the basis of the actual 
 14.27  diagnosis; 
 14.28     (4) the enrollee's efforts to follow the health plan 
 14.29  company's established procedures for obtaining emergency care; 
 14.30  and 
 14.31     (5) any circumstances that precluded use of the health plan 
 14.32  company's established procedures for obtaining emergency care. 
 14.33     (b) The health plan company may require enrollees to notify 
 14.34  the health plan company of nonreferred emergency care as soon as 
 14.35  possible, but not less than 48 hours, after the emergency care 
 14.36  is initially provided.  However, emergency care which would have 
 15.1   been provided under the contract had notice been provided within 
 15.2   the set time frame must be covered. 
 15.3      Sec. 13.  [62Q.56] [CONTINUITY OF CARE.] 
 15.4      Subdivision 1.  [CHANGE IN HEALTH PLANS.] (a) A health plan 
 15.5   company must provide coverage for all covered services provided 
 15.6   to a new enrollee by a health care provider who is not a member 
 15.7   of the health plan company's provider network or is not under 
 15.8   contract with the health plan company to provide health services 
 15.9   if at the time of enrollment the enrollee is receiving an 
 15.10  ongoing course of treatment from that health care provider and 
 15.11  meets one of the following conditions: 
 15.12     (1) has a life-threatening physical condition, mental 
 15.13  condition, or chronic health care condition; 
 15.14     (2) has a degenerative disease, physical disability, mental 
 15.15  illness, chronic health care condition, or mental retardation or 
 15.16  other related conditions; 
 15.17     (3) has entered the second trimester of pregnancy prior to 
 15.18  the time of enrollment; 
 15.19     (4) is receiving culturally appropriate services and the 
 15.20  health plan company does not have a provider in its preferred 
 15.21  provider network with special expertise in the delivery of these 
 15.22  culturally appropriate services; or 
 15.23     (5) does not speak English and the health plan company does 
 15.24  not have a provider in its preferred provider network that 
 15.25  speaks the language spoken by the enrollee. 
 15.26     (b) This subdivision applies only to group coverage and 
 15.27  continuation and conversion coverage. 
 15.28     Subd. 2.  [CHANGE IN HEALTH CARE PROVIDER.] If a health 
 15.29  care provider leaves a health plan company provider network or 
 15.30  if a health plan company terminates the contract of a provider 
 15.31  for reasons other than a violation of the provider's license, 
 15.32  the health plan company must continue to provide coverage for 
 15.33  all covered services provided by the health care provider to an 
 15.34  enrollee of the health plan if at the time of termination the 
 15.35  provider is providing services to the enrollee for an ongoing 
 15.36  course of treatment. 
 16.1      Subd. 3.  [LIMITATIONS.] (a) Subdivisions 1 and 2 apply 
 16.2   only if the enrollee's health care provider agrees to: 
 16.3      (1) accept as payment in full the health plan company's 
 16.4   reimbursement rate for out-of-network providers for the same or 
 16.5   similar services; 
 16.6      (2) adhere to the health plan company's preauthorization 
 16.7   requirements; and 
 16.8      (3) provide the health plan company with all necessary 
 16.9   medical information related to the care provided to the enrollee.
 16.10     (b) An enrollee may receive coverage for all covered 
 16.11  services related to an ongoing course of treatment as described 
 16.12  in subdivision 2 for a period of up to 120 days, or through 
 16.13  delivery if the enrollee is pregnant.  This limitation may be 
 16.14  extended by agreement of the health plan company, health care 
 16.15  provider, and the enrollee.  
 16.16     (c) Nothing in this section requires a health plan to 
 16.17  provide coverage for a health care service or treatment that is 
 16.18  not covered under the enrollee's health plan. 
 16.19     Sec. 14.  [62Q.58] [ACCESS TO SPECIALTY CARE.] 
 16.20     Subdivision 1.  [STANDING REFERRAL.] A health plan company 
 16.21  must establish a procedure by which enrollees may apply for and, 
 16.22  if appropriate, receive a standing referral to a health care 
 16.23  provider who is a specialist.  This procedure for a standing 
 16.24  referral must specify the necessary managed care review and 
 16.25  approval an enrollee must obtain before such a standing referral 
 16.26  is permitted. 
 16.27     Subd. 2.  [MANDATORY STANDING REFERRAL.] An enrollee who 
 16.28  requests a standing referral to a specialist must be given a 
 16.29  standing referral to an appropriate specialist if the enrollee 
 16.30  meets any of the following conditions: 
 16.31     (1) has a life-threatening physical condition, mental 
 16.32  condition, or chronic health care condition; 
 16.33     (2) has a degenerative disease, physical disability, mental 
 16.34  illness, chronic health care condition, or mental retardation or 
 16.35  other related conditions; or 
 16.36     (3) has entered the second trimester of pregnancy and the 
 17.1   pregnancy has been assessed by the health plan as high risk.  
 17.2      Subd. 3.  [COORDINATION OF SERVICES.] An enrollee who 
 17.3   receives a standing referral under subdivision 1 or 2 may 
 17.4   request that the health plan company permit the specialist to 
 17.5   become the enrollee's primary care provider and manage all 
 17.6   medical care appropriate to the enrollee, including primary 
 17.7   care, authorization of tests and services, and all other 
 17.8   services covered under the enrollee benefit plan.  Health plan 
 17.9   companies must establish a procedure for approval of a request 
 17.10  for coordination of services through a relevant specialist.  
 17.11     Subd. 4.  [DISCLOSURE.] A clear statement of the procedures 
 17.12  established under subdivisions 1 to 3 must be included as part 
 17.13  of any direct-marketing materials and enrollment packets and 
 17.14  evidence of coverage provided to consumers.  
 17.15     Sec. 15.  [62Q.62] [PROHIBITION ON EXCLUSIVE ARRANGEMENTS.] 
 17.16     Subdivision 1.  [EXCLUSIVE ARRANGEMENT.] For purposes of 
 17.17  this section, "exclusive arrangement" means any agreement or 
 17.18  contract, including but not limited to, acquisition, purchase, 
 17.19  affiliation, or consulting agreements with a health plan company 
 17.20  or health care provider, which has the purpose or effect of:  
 17.21     (1) committing any person providing health care services to 
 17.22  accept and treat as patients the enrollees of a health plan 
 17.23  company to the exclusion of enrollees who have coverage through 
 17.24  any other health plan company; 
 17.25     (2) providing reimbursement on sliding scales, capitation 
 17.26  rates, payment schedules, or other payment arrangements as a 
 17.27  financial incentive for persons providing health care services 
 17.28  to restrict treatment to enrollees who have coverage through any 
 17.29  other health plan company; 
 17.30     (3) providing reimbursement on sliding scales, capitation 
 17.31  rates, payment schedules, or other payment arrangements that 
 17.32  contain a financial penalty for failing to restrict treatment to 
 17.33  enrollees who have coverage through any other health plan 
 17.34  company; 
 17.35     (4) restricting any person's right to provide health 
 17.36  services, goods, or procedures to another provider or health 
 18.1   plan company; or 
 18.2      (5) preventing any person providing goods or health care 
 18.3   services from contracting with any health plan company or 
 18.4   provider. 
 18.5      Subd. 2.  [PROHIBITION.] No provider or health plan company 
 18.6   shall enter into any new exclusive arrangement or renew an 
 18.7   existing exclusive arrangement with any person, unless the 
 18.8   person is an employee.  No provider or health plan company shall 
 18.9   maintain any existing exclusive arrangement or engage in any act 
 18.10  or practice that would result in exclusive arrangements with any 
 18.11  person, unless that person is an employee.  
 18.12     Subd. 3.  [ENFORCEMENT.] (a) The commissioners of health 
 18.13  and commerce shall each periodically review contracts and 
 18.14  arrangements among health care providing entities and health 
 18.15  plan companies they regulate to determine compliance with this 
 18.16  section.  Any person may submit a contract or arrangement to the 
 18.17  relevant commissioner for review if the person believes this 
 18.18  section has been violated.  Any provision of a contract or 
 18.19  arrangement found by the relevant commissioner to violate this 
 18.20  section is null and void, and the relevant commissioner may 
 18.21  assess civil penalties against the health plan company in an 
 18.22  amount not to exceed $2,500 for each day the contract is in 
 18.23  effect and may use the enforcement procedures otherwise 
 18.24  available to the commissioner.  
 18.25     (b) A health-related licensing board as defined under 
 18.26  section 214.01, subdivision 2, may submit a contract or 
 18.27  arrangement to the relevant commissioner for review if the board 
 18.28  believes this section has been violated.  If the commissioner 
 18.29  determines that any provision of a contract or arrangement 
 18.30  violates this section, the board may take disciplinary action 
 18.31  against any person who is licensed or regulated by the board who 
 18.32  entered into the contract or arrangement.  
 18.33     Sec. 16.  Minnesota Statutes 1996, section 181.932, 
 18.34  subdivision 1, is amended to read: 
 18.35     Subdivision 1.  [PROHIBITED ACTION.] An employer shall not 
 18.36  discharge, discipline, threaten, otherwise discriminate against, 
 19.1   or penalize an employee regarding the employee's compensation, 
 19.2   terms, conditions, location, or privileges of employment because:
 19.3      (a) the employee, or a person acting on behalf of an 
 19.4   employee, in good faith, reports a violation or suspected 
 19.5   violation of any federal or state law or rule adopted pursuant 
 19.6   to law to an employer or to any governmental body or law 
 19.7   enforcement official; 
 19.8      (b) the employee is requested by a public body or office to 
 19.9   participate in an investigation, hearing, inquiry; or 
 19.10     (c) the employee refuses an employer's order to perform an 
 19.11  action that the employee has an objective basis in fact to 
 19.12  believe violates any state or federal law or rule or regulation 
 19.13  adopted pursuant to law, and the employee informs the employer 
 19.14  that the order is being refused for that reason; or 
 19.15     (d) the employee, in good faith, reports a situation in 
 19.16  which the quality of the health care services provided by a 
 19.17  health care facility, organization, or health care provider 
 19.18  places the public at risk of harm.  
 19.19     Sec. 17.  [HEALTH COVERAGE COMPLAINT RESOLUTION; 
 19.20  SELF-INSURED PLANS.] 
 19.21     The commissioner of commerce shall apply to the United 
 19.22  States Department of Labor for authority to investigate and 
 19.23  resolve health coverage complaints of enrollees in self-insured 
 19.24  health plans, on substantially the same basis as the authority 
 19.25  granted to the Oklahoma insurance department. 
 19.26     Sec. 18.  [REPEALER.] 
 19.27     Minnesota Statutes 1996, sections 62Q.105, subdivisions 2, 
 19.28  3, 4, and 8; and 62Q.11, are repealed. 
 19.29     Sec. 19.  [APPROPRIATION.] 
 19.30     $....... is appropriated from the general fund to the 
 19.31  commissioner of administration to contract for the operation of 
 19.32  the health care consumer assistance program established under 
 19.33  section 5.  The appropriation is available until expended. 
 19.34     Sec. 20.  [EFFECTIVE DATES.] 
 19.35     (a) Sections 1, 7, 10, and 17 are effective the day 
 19.36  following final enactment. 
 20.1      (b) Sections 2 to 4, 8, and 12 to 16 are effective August 
 20.2   1, 1997. 
 20.3      (c) Section 5 is effective July 1, 1997, and the consumer 
 20.4   advisory board members must be appointed by that date.  The 
 20.5   health care consumer assistance program must be implemented by 
 20.6   January 1, 1998. 
 20.7      (d) Sections 6, 10, and 11 are effective January 1, 1998.