SF 1319

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

  1.1                          A bill for an act 
  1.2             relating to health; creating an independent health 
  1.3             care ombudsman; providing criminal penalties; 
  1.4             appropriating money; proposing coding for new law in 
  1.5             Minnesota Statutes, chapter 62J. 
  1.6   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.7                 OMBUDSMAN FOR HEALTH CARE CONSUMERS
  1.8      Section 1.  [62J.71] [DEFINITIONS.] 
  1.9      Subdivision 1.  [SCOPE.] For purposes of sections 62J.71 to 
  1.10  62J.79, the following terms shall have the meanings given them. 
  1.11     Subd. 2.  [ACT.] "Act" means an action, decision, failure 
  1.12  to act, omission, rule or regulation, interpretation, 
  1.13  recommendation, policy, practice, or procedure of a health plan 
  1.14  company within the scope of the ombudsman's authority.  
  1.15     Subd. 3.  [AGENCY.] "Agency" means a division, official, or 
  1.16  employee of the department of health, commerce, or human 
  1.17  services, or a designated county social services agency as 
  1.18  described under section 256G.02, subdivision 7. 
  1.19     Subd. 4.  [COMPLAINANT.] "Complainant" means a person, 
  1.20  organization, or other entity that makes a complaint to an 
  1.21  ombudsman service regarding the acts of a health plan company. 
  1.22     Subd. 5.  [CONSUMER.] "Consumer" means a person served by a 
  1.23  health plan company who is receiving health care services or 
  1.24  treatment. 
  1.25     Subd. 6.  [HEALTH PLAN COMPANY.] "Health plan company" 
  2.1   includes, but is not limited to: 
  2.2      (1) a health carrier as defined under section 62A.011, 
  2.3   subdivision 2; 
  2.4      (2) a community integrated service network as defined under 
  2.5   section 62N.02, subdivision 4a; or 
  2.6      (3) an employee benefit plan covered by the Employee 
  2.7   Retirement and Income Security Act (ERISA), as defined under 
  2.8   United States Code, title 29, section 1002, as amended through 
  2.9   August 14, 1991. 
  2.10     Subd. 7.  [OMBUDSMAN.] "Ombudsman" means a person who is an 
  2.11  independent official intermediary between a consumer and 
  2.12  government or government regulated services and entities and who 
  2.13  receives complaints from aggrieved consumers against health plan 
  2.14  companies and reviews, investigates, and makes recommendations 
  2.15  to remedy the complaints. 
  2.16     Subd. 8.  [RECORD.] "Record" means a document, book, paper, 
  2.17  file, photograph, microfilm, sound recording, video recording, 
  2.18  stored computer data, or any other recorded information, 
  2.19  regardless of physical form, possessed or controlled by a health 
  2.20  plan company.  
  2.21     Subd. 9.  [SPECIALTY OMBUDSMAN.] "Specialty ombudsman" 
  2.22  means the office of the ombudsman for older Minnesotans as 
  2.23  defined under sections 256.974 to 256.9744; office of the 
  2.24  ombudsman for mental health and mental retardation as defined 
  2.25  under sections 245.91 to 245.97; and the office of the 
  2.26  ombudsperson for prepaid health care programs as defined under 
  2.27  section 256B.69, subdivision 20. 
  2.28     Sec. 2.  [62J.72] [OMBUDSMAN; QUALIFICATIONS; FUNCTION.] 
  2.29     Subdivision 1.  [SELECTION; QUALIFICATIONS.] An ombudsman 
  2.30  shall be appointed by the governor to serve in the unclassified 
  2.31  service.  An ombudsman shall be selected without regard to 
  2.32  political affiliation.  An ombudsman shall be a person who has 
  2.33  knowledge and experience concerning the needs and rights of 
  2.34  health care consumers and who is qualified to analyze questions 
  2.35  of law, administrative functions, and public policy.  An 
  2.36  ombudsman may not hold any other public office.  An ombudsman 
  3.1   may only be removed for just cause. 
  3.2      Subd. 2.  [FUNCTION.] The ombudsman shall promote high 
  3.3   standards of treatment, competence, efficiency, and justice.  
  3.4   The ombudsman shall have the authority, upon complaint or the 
  3.5   ombudsman's motion, to review or investigate decisions, acts, 
  3.6   and other matters of a health plan company.  
  3.7      Sec. 3.  [62J.73] [OFFICE ORGANIZATION.] 
  3.8      Subdivision 1.  [STAFF.] The ombudsman shall select and 
  3.9   compensate staff to discharge the ombudsman's responsibility.  
  3.10  The ombudsman shall ensure that staff is adequately trained to 
  3.11  handle new developments and changes in the health care system. 
  3.12     Subd. 2.  [DELEGATION.] The ombudsman may delegate to staff 
  3.13  members any of the ombudsman's authority or duties, except the 
  3.14  duty of formally making recommendations or reports. 
  3.15     Subd. 3.  [BENEFITS.] The ombudsman and staff members shall 
  3.16  be included in the Minnesota state retirement association. 
  3.17     Sec. 4.  [62J.74] [GENERAL DUTIES AND POWERS OF AN 
  3.18  OMBUDSMAN; REVIEWS AND EVALUATIONS; COMPLAINTS; 
  3.19  RECOMMENDATIONS.] 
  3.20     Subdivision 1.  [GENERAL DUTIES AND POWERS.] The ombudsman, 
  3.21  within the scope of the ombudsman's authority, may:  
  3.22     (1) assist a consumer with health care plan selection by 
  3.23  providing information, referrals, and assistance regarding means 
  3.24  of obtaining health coverage and services; 
  3.25     (2) mediate or advocate on behalf of a consumer; 
  3.26     (3) assist a consumer in understanding rights and 
  3.27  responsibilities as a health plan member; 
  3.28     (4) review and investigate an act of a health plan company; 
  3.29     (5) determine the complaint procedure used by the office; 
  3.30     (6) determine the scope and manner of investigations by the 
  3.31  ombudsman's office; 
  3.32     (7) maintain as private data the identities of complainants 
  3.33  or informants when requested by the individual who is the 
  3.34  subject of the data; 
  3.35     (8) gather and analyze information concerning the acts of a 
  3.36  health plan company; 
  4.1      (9) subpoena a person to appear, give testimony, or produce 
  4.2   records or other evidence that the ombudsman considers relevant 
  4.3   to a matter under review or investigation; 
  4.4      (10) petition the appropriate court to enforce the 
  4.5   provisions of sections 62J.71 to 62J.79; 
  4.6      (11) enter and inspect premises in the course of conducting 
  4.7   a review or investigation on a matter within the scope of the 
  4.8   ombudsman's authority; 
  4.9      (12) have access to health plan company data, 
  4.10  notwithstanding chapter 13 or any other provision of state law, 
  4.11  when the data relates to a matter that is within the scope of 
  4.12  the ombudsman's authority.  The data shall be retained by the 
  4.13  ombudsman according to data classification under chapter 13; 
  4.14     (13) set reasonable deadlines for a health plan company to 
  4.15  respond to requests for information; 
  4.16     (14) make recommendations and comments to the legislature 
  4.17  and health plan companies concerning laws, rules, regulations, 
  4.18  and policies affecting consumers; 
  4.19     (15) make recommendations to the legislature and health 
  4.20  plan companies concerning how to strengthen procedures and 
  4.21  practices that minimize the risk that objectionable health plan 
  4.22  company acts will occur; 
  4.23     (16) promote collaboration and cooperation with community 
  4.24  consumer advocacy organizations and their efforts; 
  4.25     (17) provide technical support for the development of 
  4.26  consumer and citizen organizations to protect and promote 
  4.27  individual rights; and 
  4.28     (18) accept grants, gifts, and bequests from public or 
  4.29  private sources to implement programs and services for 
  4.30  designated citizens. 
  4.31     Subd. 2.  [COMPLAINTS.] The ombudsman may receive a 
  4.32  complaint from any source concerning an act of a health plan 
  4.33  company.  After completing a review or investigation, the 
  4.34  ombudsman may inform the complainant and the health plan company 
  4.35  of the ombudsman's findings. 
  4.36     Subd. 3.  [INVESTIGATIONS OF COMPLAINTS.] (a) The ombudsman 
  5.1   may investigate any complaint within the scope of the 
  5.2   ombudsman's authority.  The ombudsman shall pay particular 
  5.3   attention but not be limited to those acts that: 
  5.4      (1) are contrary to law, rule, or agency practice; 
  5.5      (2) are based on mistaken facts or irrelevant 
  5.6   considerations; 
  5.7      (3) are unclear or inadequately explained when reasons 
  5.8   should have been revealed; 
  5.9      (4) are inefficiently performed; 
  5.10     (5) are unreasonable, unfair, or otherwise objectionable, 
  5.11  even though in accordance with law; 
  5.12     (6) may result in abuse or neglect of a person; or 
  5.13     (7) may impede or improve the monitoring or evaluation of 
  5.14  services provided. 
  5.15     (b) The ombudsman may decide not to investigate because: 
  5.16     (1) the complainant could reasonably be expected to use 
  5.17  another remedy or procedure for redress of a grievance, in which 
  5.18  case the ombudsman may furnish the person with information on 
  5.19  the alternative remedy or channel; 
  5.20     (2) the complaint is trivial, frivolous, vexatious, or not 
  5.21  made in good faith; 
  5.22     (3) the complaint has been delayed too long to justify 
  5.23  present investigation; or 
  5.24     (4) the ombudsman's resources are insufficient for adequate 
  5.25  investigation, in which case the ombudsman shall attempt to 
  5.26  refer the complaint to another authority. 
  5.27     (c) The ombudsman's decision not to investigate a specific 
  5.28  complaint shall not bar the ombudsman from reviewing, on the 
  5.29  ombudsman's motion, acts of a health plan company whether or not 
  5.30  included in a complaint. 
  5.31     Subd. 4.  [RECOMMENDATIONS.] If, after reviewing the 
  5.32  complaint or conducting the investigation and considering the 
  5.33  response of a health plan company or any other pertinent 
  5.34  material, the ombudsman determines that the complaint has merit 
  5.35  or the investigation reveals a problem, the ombudsman may 
  5.36  recommend to the health plan company and to the appropriate 
  6.1   agency that the health plan company or the appropriate agency: 
  6.2      (1) consider the matter further; 
  6.3      (2) modify or cancel its actions; 
  6.4      (3) alter a rule, order, or internal policy; 
  6.5      (4) explain more fully the action in question; 
  6.6      (5) rectify an omission; or 
  6.7      (6) take other action. 
  6.8   At the ombudsman's request, the health plan company shall, 
  6.9   within a reasonable time, inform the ombudsman about the action 
  6.10  taken on the recommendation or the reasons for not complying 
  6.11  with it. 
  6.12     Subd. 5.  [CRIMINAL OR DISCIPLINARY ACTS.] If the ombudsman 
  6.13  believes that a person has acted in a manner warranting criminal 
  6.14  or disciplinary proceedings, the ombudsman may refer the matter 
  6.15  to the appropriate authorities without notice to the person. 
  6.16     Sec. 5.  [62J.75] [DUTIES OF HEALTH PLAN COMPANIES.] 
  6.17     Subdivision 1.  [DUTIES.] Health plan companies are 
  6.18  required to: 
  6.19     (1) cooperate in the ombudsman's review or investigation of 
  6.20  the acts of the health plan company, including making records 
  6.21  and data available to the ombudsman; 
  6.22     (2) respond to an ombudsman's request for information 
  6.23  within 30 days, except when some other reasonable deadline has 
  6.24  been set by the ombudsman, in which case the deadline set by the 
  6.25  ombudsman must be met; and 
  6.26     (3) review recommendations issued by the ombudsman under 
  6.27  section 62J.74, subdivision 4, and at the ombudsman's request 
  6.28  and within a reasonable time, inform the ombudsman of the action 
  6.29  taken on the recommendation or the reason for not complying with 
  6.30  the recommendation. 
  6.31     Subd. 2.  [RETALIATION.] No person may be punished or the 
  6.32  general condition of the person's treatment be unfavorably 
  6.33  altered as a result of a review or investigation, a complaint by 
  6.34  the person, or a complaint by another person on that person's 
  6.35  behalf.  A person who violates this provision is guilty of a 
  6.36  misdemeanor. 
  7.1      Subd. 3.  [ORDER TO COMPEL COMPLIANCE.] The ombudsman may 
  7.2   apply to a district court, upon notice, and the court, on a 
  7.3   showing by the ombudsman of cause, may issue an order as may be 
  7.4   required to compel compliance with this section.  
  7.5      Sec. 6.  [62J.76] [COOPERATION; DUPLICATION.] 
  7.6      Subdivision 1.  [SPECIALTY OMBUDSMAN; DELEGATION.] The 
  7.7   ombudsman shall promote coordination and avoid duplication.  
  7.8   When the ombudsman receives a complaint from a complainant with 
  7.9   issues relating to areas covered by a specialty ombudsman, the 
  7.10  ombudsman shall receive the complaint and delegate the review or 
  7.11  investigation of the complaint to the specialty ombudsman, as 
  7.12  appropriate.  If a complaint is delegated to the specialty 
  7.13  ombudsman, the specialty ombudsman shall operate under the 
  7.14  authority of sections 62J.71 to 62J.79.  The specialty ombudsman 
  7.15  shall report the outcome of the complaint, regardless of whether 
  7.16  any action was taken to the ombudsman. 
  7.17     Subd. 2.  [LEGAL SERVICES.] The ombudsman shall promote 
  7.18  cooperation and avoid duplication with legal assistance 
  7.19  providers serving low-income and other vulnerable health care 
  7.20  consumers and the protection and advocacy system for individuals 
  7.21  with disabilities to enhance the quality of services of 
  7.22  consumers. 
  7.23     Sec. 7.  [62J.77] [CIVIL ACTIONS.] 
  7.24     The ombudsman and designees of the ombudsman are not 
  7.25  civilly liable for any action taken under sections 62J.71 to 
  7.26  62J.79 if the action was taken in good faith, was within the 
  7.27  scope of the ombudsman's authority, and did not constitute 
  7.28  willful or reckless misconduct. 
  7.29     Sec. 8.  [62J.78] [NO COMPELLED TESTIMONY.] 
  7.30     Neither the ombudsman or any member of the ombudsman's 
  7.31  staff may be compelled to testify or produce evidence in any 
  7.32  judicial or administrative proceeding with respect to matters 
  7.33  involving the exercise of official duties, except as may be 
  7.34  necessary to enforce the provisions of this chapter. 
  7.35     Sec. 9.  [62J.79] [REPORTS.] 
  7.36     In addition to reports the ombudsman may make during the 
  8.1   course of exercising the ombudsman's duties, the ombudsman shall 
  8.2   report biennially to the governor concerning the exercise of 
  8.3   functions during the proceeding biennium.  The report is due 
  8.4   during the first legislative session of a biennium. 
  8.5      Sec. 10.  [APPROPRIATION.] 
  8.6      $....... is appropriated from the general fund to the 
  8.7   commissioner of health to establish the office of the ombudsman 
  8.8   for health care, to be available until June 30, 1999.