SF 2617

as introduced - 83rd Legislature (2003 - 2004) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to health; providing for patient protections; 
  1.3             amending Minnesota Statutes 2002, sections 62A.60; 
  1.4             62J.71, subdivision 3; 62J.80; 62M.05, subdivisions 
  1.5             3a, 3b; 62M.07; 62M.09, subdivision 3; 62Q.53, 
  1.6             subdivisions 1, 2; 62Q.58, subdivision 3, by adding 
  1.7             subdivisions; 62Q.73, subdivision 7; proposing coding 
  1.8             for new law in Minnesota Statutes, chapter 62Q. 
  1.9   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.10     Section 1.  Minnesota Statutes 2002, section 62A.60, is 
  1.11  amended to read: 
  1.12     62A.60 [RETROACTIVE DENIAL OF EXPENSES.] 
  1.13     In cases where the subscriber or insured is liable for 
  1.14  costs beyond applicable co-payments or deductibles, no insurer 
  1.15  may retroactively deny payment to a person who is covered when 
  1.16  the services are provided for health care services that are 
  1.17  otherwise covered, if the insurer or its representative failed 
  1.18  to provide prior or concurrent review or authorization for the 
  1.19  expenses when required to do so under the policy, plan, or 
  1.20  certificate.  If prior or concurrent review or authorization was 
  1.21  provided by the insurer or its representative, and the 
  1.22  preexisting condition limitation provision, the general 
  1.23  exclusion provision and any other coinsurance, or other policy 
  1.24  requirements have been met, the insurer may not deny payment for 
  1.25  the authorized service or time period except in cases where 
  1.26  fraud or substantive misrepresentation occurred A health carrier 
  1.27  that has given preauthorization approval for a service or 
  2.1   treatment may not subsequently deny payment for that service or 
  2.2   treatment except in cases of fraud.  At the time a decision 
  2.3   regarding the medical necessity of a service or treatment is 
  2.4   communicated to an enrollee according to section 62M.05, a 
  2.5   health carrier shall also communicate whether the requested 
  2.6   service or treatment is a covered benefit. 
  2.7      Sec. 2.  Minnesota Statutes 2002, section 62J.71, 
  2.8   subdivision 3, is amended to read: 
  2.9      Subd. 3.  [RETALIATION PROHIBITED.] No person, health plan 
  2.10  company, or other organization may take retaliatory action 
  2.11  against a health care provider solely on the grounds that the 
  2.12  provider: 
  2.13     (1) refused to enter into an agreement or provide services 
  2.14  or information in a manner that is prohibited under this section 
  2.15  or took any of the actions listed in subdivision 1; 
  2.16     (2) disclosed accurate information about whether a health 
  2.17  care service or treatment is covered by an enrollee's health 
  2.18  plan company, health insurer, or health coverage plan; 
  2.19     (3) discussed diagnostic, treatment, or referral options 
  2.20  that are not covered or are limited by the enrollee's health 
  2.21  plan company, health insurer, or health coverage plan; 
  2.22     (4) criticized coverage of the enrollee's health plan 
  2.23  company, health insurer, or health coverage plan; or 
  2.24     (5) expressed personal disagreement with a decision made by 
  2.25  a person, organization, or health care provider regarding 
  2.26  treatment or coverage provided to a patient of the provider, or 
  2.27  assisted or advocated for the patient in seeking reconsideration 
  2.28  of such a decision, provided the health care provider makes it 
  2.29  clear that the provider is acting in a personal capacity and not 
  2.30  as a representative of or on behalf of the entity that made the 
  2.31  decision; 
  2.32     (6) disclosed, in good faith, information relating to the 
  2.33  care, services, or conditions affecting an enrollee to an 
  2.34  appropriate public agency, private accreditation body, or 
  2.35  management personnel of the health plan company as otherwise 
  2.36  allowed by law; 
  3.1      (7) initiated, cooperated with, or otherwise participated 
  3.2   in a utilization review under chapter 62M or in an investigation 
  3.3   or proceeding by a public agency; 
  3.4      (8) provided, as otherwise allowed by law, testimony, 
  3.5   evidence, records, or other assistance to an enrollee or public 
  3.6   agency; 
  3.7      (9) advocated on behalf of an enrollee who brings a claim 
  3.8   against a health carrier or otherwise participated in a claim 
  3.9   brought against a health carrier; or 
  3.10     (10) referred a patient for a second opinion under section 
  3.11  62Q.59. 
  3.12     Sec. 3.  Minnesota Statutes 2002, section 62J.80, is 
  3.13  amended to read: 
  3.14     62J.80 [RETALIATION AGAINST ENROLLEE OR PATIENT.] 
  3.15     A health plan company or health care provider shall not 
  3.16  retaliate or take adverse action against an enrollee or patient 
  3.17  who, in good faith, makes a complaint against a health plan 
  3.18  company or health care provider, participates in a utilization 
  3.19  review under chapter 62M, or obtains a second opinion under 
  3.20  section 62Q.59.  If retaliation is suspected, the executive 
  3.21  director may report it to the appropriate regulatory authority.  
  3.22     Sec. 4.  Minnesota Statutes 2002, section 62M.05, 
  3.23  subdivision 3a, is amended to read: 
  3.24     Subd. 3a.  [STANDARD REVIEW DETERMINATION.] (a) 
  3.25  Notwithstanding subdivision 3b, an initial determination on all 
  3.26  requests for utilization review must be communicated to the 
  3.27  provider and enrollee in accordance with this subdivision within 
  3.28  ten business days of the request, provided that all information 
  3.29  reasonably necessary to make a determination on the request has 
  3.30  been made available to the utilization review organization.  
  3.31     (b) When an initial determination is made to certify, 
  3.32  notification must be provided promptly by telephone to the 
  3.33  provider.  The utilization review organization shall send 
  3.34  written notification to the provider or shall maintain an audit 
  3.35  trail of the determination and telephone notification.  For 
  3.36  purposes of this subdivision, "audit trail" includes 
  4.1   documentation of the telephone notification, including the date; 
  4.2   the name of the person spoken to; the enrollee; the service, 
  4.3   procedure, or admission certified; and the date of the service, 
  4.4   procedure, or admission.  If the utilization review organization 
  4.5   indicates certification by use of a number, the number must be 
  4.6   called the "certification number." 
  4.7      (c) When an initial determination is made not to certify, 
  4.8   notification must be provided by telephone within one working 
  4.9   day after making the determination to the attending health care 
  4.10  professional and hospital and a written notification must be 
  4.11  sent to the hospital, attending health care professional, and 
  4.12  enrollee.  The written notification must include the principal 
  4.13  reason or reasons for the determination and the process for 
  4.14  initiating an appeal of the determination.  Upon request, the 
  4.15  utilization review organization shall provide the provider or 
  4.16  enrollee with the criteria used to determine the necessity, 
  4.17  appropriateness, and efficacy of the health care service and 
  4.18  identify the database, professional treatment parameter, or 
  4.19  other basis for the criteria.  Reasons for a determination not 
  4.20  to certify may include, among other things, the lack of adequate 
  4.21  information to certify after a reasonable attempt has been made 
  4.22  to contact the provider or enrollee. 
  4.23     (d) When an initial determination is made not to certify, 
  4.24  the written notification must inform the enrollee and the 
  4.25  attending health care professional of the right to submit an 
  4.26  appeal to the internal appeal process described in section 
  4.27  62M.06 and the procedure for initiating the internal appeal and 
  4.28  of the right to obtain a second opinion under section 62Q.59. 
  4.29     Sec. 5.  Minnesota Statutes 2002, section 62M.05, 
  4.30  subdivision 3b, is amended to read: 
  4.31     Subd. 3b.  [EXPEDITED REVIEW DETERMINATION.] (a) An 
  4.32  expedited initial determination must be utilized if the 
  4.33  attending health care professional believes that an expedited 
  4.34  determination is warranted. 
  4.35     (b) Notification of an expedited initial determination to 
  4.36  either certify or not to certify must be provided to the 
  5.1   hospital, the attending health care professional, and the 
  5.2   enrollee as expeditiously as the enrollee's medical condition 
  5.3   requires, but no later than 72 hours from the initial request.  
  5.4   When an expedited initial determination is made not to certify, 
  5.5   the utilization review organization must also notify the 
  5.6   enrollee and the attending health care professional of the right 
  5.7   to submit an appeal to the expedited internal appeal as 
  5.8   described in section 62M.06 and the procedure for initiating an 
  5.9   internal expedited appeal and of the right to obtain a second 
  5.10  opinion under section 62Q.59. 
  5.11     Sec. 6.  Minnesota Statutes 2002, section 62M.07, is 
  5.12  amended to read: 
  5.13     62M.07 [PRIOR AUTHORIZATION OF SERVICES.] 
  5.14     (a) Utilization review organizations conducting prior 
  5.15  authorization of services must have and follow written standards 
  5.16  that meet at a minimum the following requirements: 
  5.17     (1) written procedures and criteria used to determine 
  5.18  whether care is appropriate, reasonable, or medically necessary; 
  5.19     (2) a system for providing prompt notification of its 
  5.20  determinations to enrollees and providers and for notifying the 
  5.21  provider, enrollee, or enrollee's designee of appeal procedures 
  5.22  under clause (4); 
  5.23     (3) compliance with section 62M.05, subdivisions 3a and 3b, 
  5.24  regarding time frames for approving and disapproving prior 
  5.25  authorization requests; 
  5.26     (4) written procedures for appeals of denials of prior 
  5.27  authorization which specify the responsibilities of the enrollee 
  5.28  and provider, and which meet the requirements of sections 62M.06 
  5.29  and 72A.285, regarding release of summary review findings; and 
  5.30     (5) procedures to ensure confidentiality of 
  5.31  patient-specific information, consistent with applicable law. 
  5.32     (b) No utilization review organization, health plan 
  5.33  company, or claims administrator may conduct or require prior 
  5.34  authorization of emergency confinement or emergency treatment.  
  5.35  The enrollee or the enrollee's authorized representative may be 
  5.36  required to notify the health plan company, claims 
  6.1   administrator, or utilization review organization as soon after 
  6.2   the beginning of the emergency confinement or emergency 
  6.3   treatment as reasonably possible. 
  6.4      (c) Each time a utilization review organization, health 
  6.5   plan company, or claims administrator determines that care is 
  6.6   not appropriate, reasonable, or medically necessary, using the 
  6.7   written procedures required under paragraph (a), clause (1), the 
  6.8   utilization review organization, health plan company, or claims 
  6.9   administrator must provide a copy of the written procedures to 
  6.10  the enrollee seeking the care. 
  6.11     Sec. 7.  Minnesota Statutes 2002, section 62M.09, 
  6.12  subdivision 3, is amended to read: 
  6.13     Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] (a) A physician 
  6.14  must review all cases in which the utilization review 
  6.15  organization has concluded that a determination not to certify 
  6.16  for clinical reasons is appropriate.  
  6.17     (b) The physician conducting the review must be licensed in 
  6.18  this state.  This paragraph does not apply to reviews conducted 
  6.19  in connection with policies issued by a health plan company that 
  6.20  is assessed less than three percent of the total amount assessed 
  6.21  by the Minnesota Comprehensive Health Association.  
  6.22     (c) The physician should must be reasonably available by 
  6.23  telephone to discuss the determination with the attending health 
  6.24  care professional physician and the enrollee or the enrollee's 
  6.25  designee.  
  6.26     (d) This subdivision does not apply to outpatient mental 
  6.27  health or substance abuse services governed by subdivision 3a. 
  6.28     Sec. 8.  Minnesota Statutes 2002, section 62Q.53, 
  6.29  subdivision 1, is amended to read: 
  6.30     Subdivision 1.  [REQUIREMENT.] No health plan that covers 
  6.31  mental health services may be offered, sold, issued, or renewed 
  6.32  in this state that requires health services, including mental 
  6.33  health services, to satisfy a definition of "medically necessary 
  6.34  care," "medical necessity," or similar term that is more 
  6.35  restrictive with respect to mental health than the definition 
  6.36  provided in subdivision 2. 
  7.1      Sec. 9.  Minnesota Statutes 2002, section 62Q.53, 
  7.2   subdivision 2, is amended to read: 
  7.3      Subd. 2.  [MINIMUM DEFINITION; MEDICALLY NECESSARY.] For 
  7.4   purposes of coverage under a health plan, "medically necessary 
  7.5   care" means health care services appropriate, in terms of type, 
  7.6   frequency, level, setting, and duration, to the enrollee's 
  7.7   diagnosis or condition, and diagnostic testing and, preventive 
  7.8   services, and health care services that are appropriate, in 
  7.9   terms of type, frequency, level, setting, and duration, to the 
  7.10  enrollee's diagnosis or condition.  Medically necessary care 
  7.11  must be consistent with generally accepted practice parameters, 
  7.12  as determined by licensed health care providers in the same or 
  7.13  similar general specialty as typically manages the condition, 
  7.14  procedure, or treatment at issue, and must: 
  7.15     (1) help restore or, establish, maintain, or improve the 
  7.16  enrollee's health condition or function; or 
  7.17     (2) prevent deterioration of the enrollee's health 
  7.18  condition or function; or 
  7.19     (3) prevent the reasonably likely onset of a health problem 
  7.20  or detect an incipient problem.  
  7.21     Sec. 10.  Minnesota Statutes 2002, section 62Q.58, is 
  7.22  amended by adding a subdivision to read: 
  7.23     Subd. 1b.  [DEFINITION; SPECIALIST.] For purposes of this 
  7.24  section, "specialist" means, with respect to a condition or 
  7.25  disease, a health care provider or health care facility that has 
  7.26  adequate expertise through appropriate training and practical 
  7.27  clinical experience, including appropriate pediatric expertise 
  7.28  in the case of a child, to provide high-quality care in treating 
  7.29  the unique condition or disease of the particular patient. 
  7.30     Sec. 11.  Minnesota Statutes 2002, section 62Q.58, is 
  7.31  amended by adding a subdivision to read: 
  7.32     Subd. 1c.  [MANDATORY SPECIALIST REFERRAL.] (a) A health 
  7.33  plan company must make or provide for a referral to an 
  7.34  appropriate participating specialist who is available and 
  7.35  accessible to treat the enrollee's condition or disease or to a 
  7.36  nonparticipating specialist if the health plan company does not 
  8.1   have an appropriate participating specialist that is available 
  8.2   and accessible to treat the enrollee's condition or disease if 
  8.3   the enrollee has a condition or disease of sufficient 
  8.4   seriousness and complexity to require treatment by a specialist. 
  8.5      (b) If an enrollee receives services from a 
  8.6   nonparticipating specialist under paragraph (a) because a 
  8.7   participating specialist is not available, services shall be 
  8.8   provided at no additional cost to the enrollee beyond what the 
  8.9   enrollee would otherwise pay for services from a participating 
  8.10  specialist. 
  8.11     Sec. 12.  Minnesota Statutes 2002, section 62Q.58, 
  8.12  subdivision 3, is amended to read: 
  8.13     Subd. 3.  [DISCLOSURE.] Information regarding referral 
  8.14  procedures under this section, including the application process 
  8.15  and criteria and conditions for a standing referral, must be 
  8.16  included in member contracts or certificates of coverage and 
  8.17  must be provided to an enrollee or prospective enrollee by a 
  8.18  health plan company upon request. 
  8.19     Sec. 13.  [62Q.59] [PROMPT EVALUATION; COVERAGE OF SECOND 
  8.20  OPINION.] 
  8.21     A health plan company shall promptly evaluate the treatment 
  8.22  needs of any enrollee who is seeking treatment for a problem 
  8.23  related to a medical condition, including mental health and 
  8.24  chemical dependency conditions.  If the health plan company, or 
  8.25  a health care provider acting on its behalf, determines that a 
  8.26  particular type of treatment is unnecessary, the enrollee is 
  8.27  immediately entitled to a second opinion paid for by the health 
  8.28  plan company from a health care provider who is qualified in the 
  8.29  diagnosis and treatment of the condition and who is chosen by 
  8.30  the enrollee, regardless of whether the provider has a contract 
  8.31  with the enrollee's health plan company.  The health plan 
  8.32  company shall promptly notify the enrollee of whether any 
  8.33  treatment recommended by the health care provider performing a 
  8.34  second opinion shall be covered.  For purposes of this section, 
  8.35  "second opinion" means an opinion rendered by a health care 
  8.36  provider qualified in the diagnosis and treatment of the problem 
  9.1   who is physically available to examine the enrollee. 
  9.2      Sec. 14.  [62Q.673] [ACCESS TO EVIDENCE OF COVERAGE AND 
  9.3   DRUG FORMULARY.] 
  9.4      Subdivision 1.  [EVIDENCE OF COVERAGE.] A health plan 
  9.5   company shall provide to a prospective enrollee, upon request, a 
  9.6   specimen copy of the certificate of coverage, subscriber 
  9.7   contract, or other evidence of coverage required to be filed 
  9.8   with the commissioner of commerce or health under chapter 62A, 
  9.9   62C, 62D, or 62N. 
  9.10     Subd. 2.  [DRUG FORMULARY.] (a) A health plan company that 
  9.11  provides a prescription drug benefit and maintains one or more 
  9.12  drug formularies shall provide an enrollee or prospective 
  9.13  enrollee, upon request: 
  9.14     (1) a copy of the most current list of prescription drugs, 
  9.15  organized by major therapeutic category, on the health plan 
  9.16  company's formulary; and 
  9.17     (2) an indication of whether any drugs on the list are 
  9.18  preferred over other listed drugs. 
  9.19     (b) If a health plan company maintains more than one drug 
  9.20  formulary for a particular health plan, the health plan company 
  9.21  shall notify the requesting enrollee or prospective enrollee 
  9.22  that a choice of formulary lists is available. 
  9.23     Sec. 15.  [62Q.674] [CHANGE IN CONTENT OF DRUG FORMULARY.] 
  9.24     A health plan that provides coverage for prescription drugs 
  9.25  may not limit or exclude coverage of a prescription drug for an 
  9.26  enrollee during the term of the contract based on the removal of 
  9.27  the drug, during the term of the contract, from a prescription 
  9.28  drug formulary used under the health plan, if the following 
  9.29  conditions are met: 
  9.30     (1) the health plan had, during the contract period, 
  9.31  covered the drug for that enrollee to treat that enrollee's 
  9.32  medical condition; 
  9.33     (2) the health care provider prescribing the drug for that 
  9.34  enrollee continues to prescribe the drug for the enrollee; and 
  9.35     (3) the drug is considered safe and effective for treating 
  9.36  the enrollee's medical condition. 
 10.1      Sec. 16.  Minnesota Statutes 2002, section 62Q.73, 
 10.2   subdivision 7, is amended to read: 
 10.3      Subd. 7.  [STANDARDS OF REVIEW.] (a) For an external review 
 10.4   of any issue in an adverse determination that does not require a 
 10.5   medical necessity determination, the external review must be 
 10.6   based on whether the adverse determination was in compliance 
 10.7   with the enrollee's health benefit plan. 
 10.8      (b) For an external review of any issue in an adverse 
 10.9   determination by a health plan company licensed under chapter 
 10.10  62D that requires a medical necessity determination, the 
 10.11  external review must determine whether the adverse determination 
 10.12  was consistent with the definition of medically necessary care 
 10.13  in Minnesota Rules, part 4685.0100, subpart 9b under section 
 10.14  62Q.53. 
 10.15     (c) For an external review of any issue in an adverse 
 10.16  determination by a health plan company, other than a health plan 
 10.17  company licensed under chapter 62D, that requires a medical 
 10.18  necessity determination, the external review must determine 
 10.19  whether the adverse determination was consistent with the 
 10.20  definition of medically necessary care in section 62Q.53, 
 10.21  subdivision 2. 
 10.22     Sec. 17.  [EFFECTIVE DATE.] 
 10.23     Sections 1 to 16 are effective January 1, 2005, and apply 
 10.24  to contracts issued or renewed on or after that date.