SF 3156

1st Unofficial Engrossment - 81st Legislature (1999 - 2000) Posted on 12/15/2009 12:00am

  1.1                          A bill for an act 
  1.2             relating to health; providing patient protections; 
  1.3             modifying the Health Care Administrative 
  1.4             Simplification Act; modifying comprehensive health 
  1.5             insurance provisions; advancing the expiration date 
  1.6             for the consumer advisory board; amending Minnesota 
  1.7             Statutes 1998, sections 62D.08, by adding a 
  1.8             subdivision; 62D.17, subdivision 1; 62E.04, 
  1.9             subdivision 4; 62J.38; 62J.51, by adding subdivisions; 
  1.10            62J.52, subdivisions 1, 2, and 5; 62J.60, subdivision 
  1.11            1; 62J.75; 62Q.56; and 62Q.58; Minnesota Statutes 1999 
  1.12            Supplement, sections 45.027, subdivision 6; and 
  1.13            62M.02, subdivision 21; proposing coding for new law 
  1.14            in Minnesota Statutes, chapters 62D; and 62J; 
  1.15            repealing Minnesota Statutes 1998, sections 16B.93; 
  1.16            16B.94; 16B.95; 16B.96; and 62D.08, subdivision 5. 
  1.17  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.18     Section 1.  Minnesota Statutes 1999 Supplement, section 
  1.19  45.027, subdivision 6, is amended to read: 
  1.20     Subd. 6.  [VIOLATIONS AND PENALTIES.] The commissioner may 
  1.21  impose a civil penalty not to exceed $10,000 per violation upon 
  1.22  a person who violates any law, rule, or order related to the 
  1.23  duties and responsibilities entrusted to the commissioner unless 
  1.24  a different penalty is specified.  If a civil penalty is imposed 
  1.25  on a health carrier as defined in section 62A.011, the 
  1.26  commissioner must divide 50 percent of the amount among any 
  1.27  policy holder or certificate holder affected by the violation, 
  1.28  unless the commissioner certifies in writing that the division 
  1.29  and distribution to enrollees would be too administratively 
  1.30  complex or that the number of enrollees affected by the penalty 
  1.31  would result in a distribution of less than $50 per enrollee.  
  2.1      Sec. 2.  [62D.021] [ACCREDITATION.] 
  2.2      The commissioner shall accept the results of private 
  2.3   accreditation organizations, professional review organizations, 
  2.4   and other governmental agencies based upon a determination that 
  2.5   the other organization's standards and procedures are no less 
  2.6   stringent than state law.  Documentation of audit procedures and 
  2.7   work papers of these audit organizations must be available to 
  2.8   the commissioner.  The commissioner may use those results in 
  2.9   exercise of regulatory authority.  The commissioner may initiate 
  2.10  and conduct any investigation deemed necessary if there is 
  2.11  suspected violation of law. 
  2.12     Sec. 3.  Minnesota Statutes 1998, section 62D.08, is 
  2.13  amended by adding a subdivision to read: 
  2.14     Subd. 5a.  [PROVIDER TERMINATIONS; NOTICE TO COMMISSIONER.] 
  2.15  Every health maintenance organization shall inform the 
  2.16  commissioner of any termination of a provider contract within 
  2.17  ten days after the date that the health maintenance organization 
  2.18  sends out or receives the notice of cancellation, 
  2.19  discontinuance, or termination. 
  2.20     Sec. 4.  Minnesota Statutes 1998, section 62D.17, 
  2.21  subdivision 1, is amended to read: 
  2.22     Subdivision 1.  The commissioner of health may, for any 
  2.23  violation of statute or rule applicable to a health maintenance 
  2.24  organization, or in lieu of suspension or revocation of a 
  2.25  certificate of authority under section 62D.15, levy an 
  2.26  administrative penalty in an amount up to $25,000 for each 
  2.27  violation.  In the case of contracts or agreements made pursuant 
  2.28  to section 62D.05, subdivisions 2 to 4, each contract or 
  2.29  agreement entered into or implemented in a manner which violates 
  2.30  sections 62D.01 to 62D.30 shall be considered a separate 
  2.31  violation.  In determining the level of an administrative 
  2.32  penalty, the commissioner shall consider the following factors: 
  2.33     (1) the number of enrollees affected by the violation; 
  2.34     (2) the effect of the violation on enrollees' health and 
  2.35  access to health services; 
  2.36     (3) if only one enrollee is affected, the effect of the 
  3.1   violation on that enrollee's health; 
  3.2      (4) whether the violation is an isolated incident or part 
  3.3   of a pattern of violations; and 
  3.4      (5) the economic benefits derived by the health maintenance 
  3.5   organization or a participating provider by virtue of the 
  3.6   violation. 
  3.7      Reasonable notice in writing to the health maintenance 
  3.8   organization shall be given of the intent to levy the penalty 
  3.9   and the reasons therefor, and the health maintenance 
  3.10  organization may have 15 days within which to file a written 
  3.11  request for an administrative hearing and review of the 
  3.12  commissioner of health's determination.  Such administrative 
  3.13  hearing shall be subject to judicial review pursuant to chapter 
  3.14  14.  If an administrative penalty is levied, the commissioner 
  3.15  must divide 50 percent of the amount among any enrollee affected 
  3.16  by the violation, unless the commissioner certifies in writing 
  3.17  that the division and distribution to enrollees would be too 
  3.18  administratively complex or that the number of enrollees 
  3.19  affected by the penalty would result in a distribution of less 
  3.20  than $50 per enrollee. 
  3.21     Sec. 5.  Minnesota Statutes 1998, section 62E.04, 
  3.22  subdivision 4, is amended to read: 
  3.23     Subd. 4.  [MAJOR MEDICAL COVERAGE.] Each insurer and 
  3.24  fraternal shall affirmatively offer coverage of major medical 
  3.25  expenses to every applicant who applies to the insurer or 
  3.26  fraternal for a new unqualified policy, which has a lifetime 
  3.27  benefit limit of less than $1,000,000, at the time of 
  3.28  application and annually to every holder of such an unqualified 
  3.29  policy of accident and health insurance renewed by the insurer 
  3.30  or fraternal.  The coverage shall provide that when a covered 
  3.31  individual incurs out-of-pocket expenses of $5,000 or more 
  3.32  within a calendar year for services covered in section 62E.06, 
  3.33  subdivision 1, benefits shall be payable, subject to any 
  3.34  copayment authorized by the commissioner, up to a maximum 
  3.35  lifetime limit of $500,000.  The offer of coverage of major 
  3.36  medical expenses may consist of the offer of a rider on an 
  4.1   existing unqualified policy or a new policy which is a qualified 
  4.2   plan. 
  4.3      Sec. 6.  Minnesota Statutes 1998, section 62J.38, is 
  4.4   amended to read: 
  4.5      62J.38 [COST CONTAINMENT DATA FROM GROUP PURCHASERS.] 
  4.6      (a) The commissioner shall require group purchasers to 
  4.7   submit detailed data on total health care spending for each 
  4.8   calendar year.  Group purchasers shall submit data for the 1993 
  4.9   calendar year by April 1, 1994, and each April 1 thereafter 
  4.10  shall submit data for the preceding calendar year. 
  4.11     (b) The commissioner shall require each group purchaser to 
  4.12  submit data on revenue, expenses, and member months, as 
  4.13  applicable.  Revenue data must distinguish between premium 
  4.14  revenue and revenue from other sources and must also include 
  4.15  information on the amount of revenue in reserves and changes in 
  4.16  reserves.  Expenditure data, including raw data from claims, may 
  4.17  must distinguish between expenses incurred for patient care and 
  4.18  administrative costs.  Expenditure data must be provided 
  4.19  separately for the following categories or and for other 
  4.20  categories required by the commissioner:  physician services, 
  4.21  dental services, other professional services, inpatient hospital 
  4.22  services, outpatient hospital services, emergency, pharmacy 
  4.23  services and other nondurable medical goods, mental health, and 
  4.24  chemical dependency services, other expenditures, subscriber 
  4.25  liability, and administrative costs.  Administrative costs must 
  4.26  include costs for marketing; advertising; overhead; salaries and 
  4.27  benefits of central office staff who do not provide direct 
  4.28  patient care; underwriting; lobbying; claims processing; 
  4.29  provider contracting and credentialing; detection and prevention 
  4.30  of payment for fraudulent or unjustified requests for 
  4.31  reimbursement or services; clinical quality assurance and other 
  4.32  types of medical care quality improvement efforts; concurrent or 
  4.33  prospective utilization review as defined in section 62M.02; 
  4.34  expenses incurred to acquire a hospital, clinic, health care 
  4.35  facility, or the assets thereof; capital costs incurred on 
  4.36  behalf of a hospital or clinic; lease payments; or any other 
  5.1   expenses incurred to a hospital, clinic, or other health care 
  5.2   provider pursuant to a partnership, joint venture, integration, 
  5.3   or affiliation agreement.  The reports of this data must also 
  5.4   separately identify expenses for local, state, and federal 
  5.5   taxes, fees, and assessments.  The commissioner may require each 
  5.6   group purchaser to submit any other data, including data in 
  5.7   unaggregated form, for the purposes of developing spending 
  5.8   estimates, setting spending limits, and monitoring actual 
  5.9   spending and costs. 
  5.10     (c) The commissioner may collect information on: 
  5.11     (1) premiums, benefit levels, managed care procedures, and 
  5.12  other features of health plan companies; 
  5.13     (2) prices, provider experience, and other information for 
  5.14  services less commonly covered by insurance or for which 
  5.15  patients commonly face significant out-of-pocket expenses; and 
  5.16     (3) information on health care services not provided 
  5.17  through health plan companies, including information on prices, 
  5.18  costs, expenditures, and utilization. 
  5.19     (d) All group purchasers shall provide the required data 
  5.20  using a uniform format and uniform definitions, as prescribed by 
  5.21  the commissioner. 
  5.22     Sec. 7.  Minnesota Statutes 1998, section 62J.51, is 
  5.23  amended by adding a subdivision to read: 
  5.24     Subd. 19a.  [UNIFORM EXPLANATION OF BENEFITS 
  5.25  DOCUMENT.] "Uniform explanation of benefits document" means the 
  5.26  document associated with and explaining the details of a group 
  5.27  purchaser's claim adjudication for services rendered, which is 
  5.28  sent to a patient. 
  5.29     Sec. 8.  Minnesota Statutes 1998, section 62J.51, is 
  5.30  amended by adding a subdivision to read: 
  5.31     Subd. 19b.  [UNIFORM REMITTANCE ADVICE REPORT.] "Uniform 
  5.32  remittance advice report" means the document associated with and 
  5.33  explaining the details of a group purchaser's claim adjudication 
  5.34  for services rendered, which is sent to a provider. 
  5.35     Sec. 9.  Minnesota Statutes 1998, section 62J.52, 
  5.36  subdivision 1, is amended to read: 
  6.1      Subdivision 1.  [UNIFORM BILLING FORM HCFA 1450.] (a) On 
  6.2   and after January 1, 1996, all institutional inpatient hospital 
  6.3   services, ancillary services, and institutionally owned or 
  6.4   operated outpatient services rendered by providers in Minnesota, 
  6.5   and institutional or noninstitutional home health services that 
  6.6   are not being billed using an equivalent electronic billing 
  6.7   format, must be billed using the uniform billing form HCFA 1450, 
  6.8   except as provided in subdivision 5. 
  6.9      (b) The instructions and definitions for the use of the 
  6.10  uniform billing form HCFA 1450 shall be in accordance with the 
  6.11  uniform billing form manual specified by the commissioner.  In 
  6.12  promulgating these instructions, the commissioner may utilize 
  6.13  the manual developed by the National Uniform Billing Committee, 
  6.14  as adopted and finalized by the Minnesota uniform billing 
  6.15  committee.  
  6.16     (c) Services to be billed using the uniform billing form 
  6.17  HCFA 1450 include:  institutional inpatient hospital services 
  6.18  and distinct units in the hospital such as psychiatric unit 
  6.19  services, physical therapy unit services, swing bed (SNF)  
  6.20  services, inpatient state psychiatric hospital services, 
  6.21  inpatient skilled nursing facility services, home health 
  6.22  services (Medicare part A), and hospice services; ancillary 
  6.23  services, where benefits are exhausted or patient has no 
  6.24  Medicare part A, from hospitals, state psychiatric hospitals, 
  6.25  skilled nursing facilities, and home health (Medicare part B); 
  6.26  and institutional owned or operated outpatient services such as 
  6.27  waivered services, hospital outpatient services, including 
  6.28  ambulatory surgical center services, hospital referred 
  6.29  laboratory services, hospital-based ambulance services, and 
  6.30  other hospital outpatient services, skilled nursing facilities, 
  6.31  home health, including infusion therapy, freestanding renal 
  6.32  dialysis centers, comprehensive outpatient rehabilitation 
  6.33  facilities (CORF), outpatient rehabilitation facilities (ORF), 
  6.34  rural health clinics, and community mental health centers,; home 
  6.35  health services such as home health intravenous therapy 
  6.36  providers, waivered services, personal care attendants, and 
  7.1   hospice; and any other health care provider certified by the 
  7.2   Medicare program to use this form. 
  7.3      (d) On and after January 1, 1996, a mother and newborn 
  7.4   child must be billed separately, and must not be combined on one 
  7.5   claim form. 
  7.6      Sec. 10.  Minnesota Statutes 1998, section 62J.52, 
  7.7   subdivision 2, is amended to read: 
  7.8      Subd. 2.  [UNIFORM BILLING FORM HCFA 1500.] (a) On and 
  7.9   after January 1, 1996, all noninstitutional health care services 
  7.10  rendered by providers in Minnesota except dental or pharmacy 
  7.11  providers, that are not currently being billed using an 
  7.12  equivalent electronic billing format, must be billed using the 
  7.13  health insurance claim form HCFA 1500, except as provided in 
  7.14  subdivision 5. 
  7.15     (b) The instructions and definitions for the use of the 
  7.16  uniform billing form HCFA 1500 shall be in accordance with the 
  7.17  manual developed by the administrative uniformity committee 
  7.18  entitled standards for the use of the HCFA 1500 form, dated 
  7.19  February 1994, as further defined by the commissioner. 
  7.20     (c) Services to be billed using the uniform billing form 
  7.21  HCFA 1500 include physician services and supplies, durable 
  7.22  medical equipment, noninstitutional ambulance services, 
  7.23  independent ancillary services including occupational therapy, 
  7.24  physical therapy, speech therapy and audiology, podiatry 
  7.25  services, optometry services, mental health licensed 
  7.26  professional services, substance abuse licensed professional 
  7.27  services, nursing practitioner professional services, certified 
  7.28  registered nurse anesthetists, chiropractors, physician 
  7.29  assistants, laboratories, medical suppliers, and other health 
  7.30  care providers such as home health intravenous therapy 
  7.31  providers, personal care attendants, day activity centers, 
  7.32  waivered services, hospice, and other home health services, and 
  7.33  freestanding ambulatory surgical centers. 
  7.34     Sec. 11.  Minnesota Statutes 1998, section 62J.52, 
  7.35  subdivision 5, is amended to read: 
  7.36     Subd. 5.  [STATE AND FEDERAL HEALTH CARE PROGRAMS.] (a) 
  8.1   Skilled nursing facilities and ICF/MR services billed to state 
  8.2   and federal health care programs administered by the department 
  8.3   of human services shall use the form designated by the 
  8.4   department of human services. 
  8.5      (b) On and after July 1, 1996, state and federal health 
  8.6   care programs administered by the department of human services 
  8.7   shall accept the HCFA 1450 for community mental health center 
  8.8   services and shall accept the HCFA 1500 for freestanding 
  8.9   ambulatory surgical center services. 
  8.10     (c) State and federal health care programs administered by 
  8.11  the department of human services shall be authorized to use the 
  8.12  forms designated by the department of human services for 
  8.13  pharmacy services and for child and teen checkup services. 
  8.14     (d) State and federal health care programs administered by 
  8.15  the department of human services shall accept the form 
  8.16  designated by the department of human services, and the HCFA 
  8.17  1500 for supplies, medical supplies, or durable medical 
  8.18  equipment.  Health care providers may choose which form to 
  8.19  submit. 
  8.20     (e) Personal care attendant and waivered services billed on 
  8.21  a fee-for-service basis directly to state and federal health 
  8.22  care programs administered by the department of human services 
  8.23  shall use either the HCFA 1450 or the HCFA 1500 form, as 
  8.24  designated by the department of human services. 
  8.25     Sec. 12.  [62J.581] [STANDARDS FOR MINNESOTA UNIFORM HEALTH 
  8.26  CARE REIMBURSEMENT DOCUMENTS.] 
  8.27     Subdivision 1.  [MINNESOTA UNIFORM REMITTANCE ADVICE 
  8.28  REPORT.] All group purchasers and payers shall provide a uniform 
  8.29  remittance advice report to health care providers when a claim 
  8.30  is adjudicated.  The uniform remittance advice report shall 
  8.31  comply with the standards prescribed in this section. 
  8.32     Subd. 2.  [MINNESOTA UNIFORM EXPLANATION OF BENEFITS 
  8.33  DOCUMENT.] All group purchasers and payers shall provide a 
  8.34  uniform explanation of benefits document to health care patients 
  8.35  when a claim is adjudicated.  The uniform explanation of 
  8.36  benefits document shall comply with the standards prescribed in 
  9.1   this section. 
  9.2      Subd. 3.  [SCOPE.] For purposes of sections 62J.50 to 
  9.3   62J.61, the uniform remittance advice report and the uniform 
  9.4   explanation of benefits document format specified in subdivision 
  9.5   4 shall apply to all health care services delivered by a health 
  9.6   care provider or health care provider organization in Minnesota, 
  9.7   regardless of the location of the payer.  Health care services 
  9.8   not paid on an individual claims basis, such as capitated 
  9.9   payments, are not included in this section.  A health plan 
  9.10  company is excluded from the requirements in subdivisions 1 and 
  9.11  2 if it complies with section 62A.01, subdivisions 2 and 3. 
  9.12     Subd. 4.  [SPECIFICATIONS.] The uniform remittance advice 
  9.13  report and the uniform explanation of benefits document shall be 
  9.14  provided by use of a paper document conforming to the 
  9.15  specifications in this section or by use of the ANSI X12N 835 
  9.16  standard electronic format as established under United States 
  9.17  Code, title 42, sections 1320d to 1320d-8, and as amended from 
  9.18  time to time for the remittance advice.  The commissioner, after 
  9.19  consulting with the administrative uniformity committee, shall 
  9.20  specify the data elements and definitions for the uniform 
  9.21  remittance advice report and the uniform explanation of benefits 
  9.22  document.  The commissioner and the administrative uniformity 
  9.23  committee must consult with the Minnesota Dental Association and 
  9.24  Delta Dental Plan of Minnesota before requiring under this 
  9.25  section the use of a paper document for the uniform explanation 
  9.26  of benefits document or the uniform remittance advice report for 
  9.27  dental care services. 
  9.28     Subd. 5.  [EFFECTIVE DATE.] The requirements in 
  9.29  subdivisions 1 and 2 are effective 12 months after the date of 
  9.30  required compliance with the standards for the electronic 
  9.31  remittance advice transaction under United States Code, title 
  9.32  42, sections 1320d to 1320d-8, as amended.  The requirements in 
  9.33  subdivisions 1 and 2 apply regardless of when the health care 
  9.34  service was provided to the patient. 
  9.35     Sec. 13.  Minnesota Statutes 1998, section 62J.60, 
  9.36  subdivision 1, is amended to read: 
 10.1      Subdivision 1.  [MINNESOTA HEALTH CARE IDENTIFICATION 
 10.2   CARD.] All individuals with health care coverage shall be issued 
 10.3   health care identification cards by group purchasers as of 
 10.4   January 1, 1998, unless the requirements of section 62A.01, 
 10.5   subdivisions 2 and 3, are met.  The health care identification 
 10.6   cards shall comply with the standards prescribed in this section.
 10.7      Sec. 14.  Minnesota Statutes 1998, section 62J.75, is 
 10.8   amended to read: 
 10.9      62J.75 [CONSUMER ADVISORY BOARD.] 
 10.10     (a) The consumer advisory board consists of 18 members 
 10.11  appointed in accordance with paragraph (b).  All members must be 
 10.12  public, consumer members who: 
 10.13     (1) do not have and never had a material interest in either 
 10.14  the provision of health care services or in an activity directly 
 10.15  related to the provision of health care services, such as health 
 10.16  insurance sales or health plan administration; 
 10.17     (2) are not registered lobbyists; and 
 10.18     (3) are not currently responsible for or directly involved 
 10.19  in the purchasing of health insurance for a business or 
 10.20  organization. 
 10.21     (b) The governor, the speaker of the house of 
 10.22  representatives, and the subcommittee on committees of the 
 10.23  committee on rules and administration of the senate shall each 
 10.24  appoint six members.  Members may be compensated in accordance 
 10.25  with section 15.059, subdivision 3, except that members shall 
 10.26  not receive per diem compensation or reimbursements for child 
 10.27  care expenses. 
 10.28     (c) The board shall advise the commissioners of health and 
 10.29  commerce on the following: 
 10.30     (1) the needs of health care consumers and how to better 
 10.31  serve and educate the consumers on health care concerns and 
 10.32  recommend solutions to identified problems; and 
 10.33     (2) consumer protection issues in the self-insured market, 
 10.34  including, but not limited to, public education needs. 
 10.35     The board also may make recommendations to the legislature 
 10.36  on these issues. 
 11.1      (d) The board and this section expire June 30, 2001 2000. 
 11.2      Sec. 15.  Minnesota Statutes 1999 Supplement, section 
 11.3   62M.02, subdivision 21, is amended to read: 
 11.4      Subd. 21.  [UTILIZATION REVIEW ORGANIZATION.] "Utilization 
 11.5   review organization" means an entity including but not limited 
 11.6   to an insurance company licensed under chapter 60A to offer, 
 11.7   sell, or issue a policy of accident and sickness insurance as 
 11.8   defined in section 62A.01; a health service plan licensed under 
 11.9   chapter 62C; a health maintenance organization licensed under 
 11.10  chapter 62D; a community integrated service network licensed 
 11.11  under chapter 62N; an accountable provider network operating 
 11.12  under chapter 62T; a fraternal benefit society operating under 
 11.13  chapter 64B; a joint self-insurance employee health plan 
 11.14  operating under chapter 62H; a multiple employer welfare 
 11.15  arrangement, as defined in section 3 of the Employee Retirement 
 11.16  Income Security Act of 1974 (ERISA), United States Code, title 
 11.17  29, section 1103, as amended; a third party administrator 
 11.18  licensed under section 60A.23, subdivision 8, which conducts 
 11.19  utilization review and determines certification of an admission, 
 11.20  extension of stay, or other health care services for a Minnesota 
 11.21  resident; or any entity performing utilization review that is 
 11.22  affiliated with, under contract with, or conducting utilization 
 11.23  review on behalf of, a business entity in this 
 11.24  state.  Utilization review organization does not include a 
 11.25  clinic or health care system acting pursuant to a written 
 11.26  delegation agreement with an otherwise regulated utilization 
 11.27  review organization which contracts with the clinic or health 
 11.28  care system.  The regulated utilization review organization is 
 11.29  accountable for the delegated utilization review activities of 
 11.30  the clinic or health care system. 
 11.31     Sec. 16.  Minnesota Statutes 1998, section 62Q.56, is 
 11.32  amended to read: 
 11.33     62Q.56 [CONTINUITY OF CARE.] 
 11.34     Subdivision 1.  [CHANGE IN HEALTH CARE PROVIDER.] (a) If 
 11.35  enrollees are required to access services through selected 
 11.36  primary care providers for coverage, the health plan company 
 12.1   shall prepare a written plan that provides for continuity of 
 12.2   care in the event of contract termination between the health 
 12.3   plan company and any of the contracted primary care providers or 
 12.4   general hospital providers.  The written plan must explain: 
 12.5      (1) how the health plan company will inform affected 
 12.6   enrollees, insureds, or beneficiaries about termination at least 
 12.7   30 days before the termination is effective, if the health plan 
 12.8   company or health care network cooperative has received at least 
 12.9   120 days' prior notice; 
 12.10     (2) how the health plan company will inform the affected 
 12.11  enrollees about what other participating providers are available 
 12.12  to assume care and how it will facilitate an orderly transfer of 
 12.13  its enrollees from the terminating provider to the new provider 
 12.14  to maintain continuity of care; 
 12.15     (3) the procedures by which enrollees will be transferred 
 12.16  to other participating providers, when special medical needs, 
 12.17  special risks, or other special circumstances, such as cultural 
 12.18  or language barriers, require them to have a longer transition 
 12.19  period or be transferred to nonparticipating providers; 
 12.20     (4) who will identify enrollees with special medical needs 
 12.21  or at special risk and what criteria will be used for this 
 12.22  determination; and 
 12.23     (5) how continuity of care will be provided for enrollees 
 12.24  identified as having special needs or at special risk, and 
 12.25  whether the health plan company has assigned this responsibility 
 12.26  to its contracted primary care providers. 
 12.27     (b) If the contract termination was not for 
 12.28  cause, enrollees can request a referral to the terminating 
 12.29  provider for up to 120 days if they have special medical needs 
 12.30  or have other special circumstances, such as cultural or 
 12.31  language barriers. the terminated provider must be notified of 
 12.32  the enrollee's rights to continuity of care with the terminated 
 12.33  provider and the health plan company must provide, upon request, 
 12.34  authorization to receive services that are otherwise covered 
 12.35  under the terms of the health plan through the enrollee's 
 12.36  current provider for the remainder of the enrollee's life if the 
 13.1   enrollee has a medical prognosis of a terminal condition with a 
 13.2   life expectancy of 180 days or less as determined by the 
 13.3   enrollee's primary care provider or, if the enrollee does not 
 13.4   have such a medical prognosis, for up to 120 days if the 
 13.5   enrollee is engaged in a current course of treatment for one or 
 13.6   more of the following conditions: 
 13.7      (1) an acute condition; 
 13.8      (2) a life-threatening mental or physical illness; 
 13.9      (3) pregnancy beyond the first trimester of pregnancy; or 
 13.10     (4) a disabling or chronic condition that is in an acute 
 13.11  phase.  
 13.12  For all requests for authorization to receive services under 
 13.13  this paragraph, the health plan company must grant the request 
 13.14  unless the enrollee does not meet the criteria provided in this 
 13.15  paragraph. 
 13.16     (c) The health plan company shall prepare a written plan 
 13.17  that provides a process for coverage determinations regarding 
 13.18  continuity of care of up to 120 days for enrollees who request 
 13.19  continuity of care with their former provider, if the enrollee: 
 13.20     (1) is receiving culturally appropriate services and the 
 13.21  health plan company does not have a provider in its preferred 
 13.22  provider network with special expertise in the delivery of these 
 13.23  culturally appropriate services within the time and distance 
 13.24  requirements of section 62D.124, subdivision 1; or 
 13.25     (2) does not speak English and the health plan company does 
 13.26  not have a provider in its preferred provider network who can 
 13.27  communicate with the enrollee, either directly or through an 
 13.28  interpreter, within the time and distance requirements of 
 13.29  section 62D.124, subdivision 1. 
 13.30  The written plan must explain the criteria that will be used to 
 13.31  determine whether a need for continuity of care exists and how 
 13.32  it will be provided. 
 13.33     (d) This paragraph applies to requests under paragraph (b) 
 13.34  or (c).  The health plan company may require medical records and 
 13.35  other supporting documentation to be submitted with the request 
 13.36  for authorization.  The health plan company must explain the 
 14.1   criteria it used to make its decision on the request for 
 14.2   authorization.  If an authorization is granted, the health plan 
 14.3   company must explain how continuity of care will be provided.  
 14.4      The health plan company can require medical records and 
 14.5   other supporting documentation in support of the requested 
 14.6   referral.  Each request for referral to a terminating provider 
 14.7   shall be considered by the health plan company on a case-by-case 
 14.8   basis. 
 14.9      (c) (e) If the contract termination was for cause, 
 14.10  enrollees must be notified of the change and transferred to 
 14.11  participating providers in a timely manner so that health care 
 14.12  services remain available and accessible to the affected 
 14.13  enrollees.  The health plan company is not required to refer an 
 14.14  enrollee back to the terminating provider if the termination was 
 14.15  for cause. 
 14.16     Subd. 2.  [CHANGE IN HEALTH PLANS.] (a) The health plan 
 14.17  company shall prepare a written plan that provides a process for 
 14.18  coverage determinations for continuity of care for new enrollees 
 14.19  with special needs, special risks, or other special 
 14.20  circumstances, such as cultural or language barriers, who 
 14.21  request continuity of care with their former provider for up to 
 14.22  120 days.  The written plan must explain the criteria that will 
 14.23  be used for determining special needs cases, and how continuity 
 14.24  of care will be provided.  If enrollees are subject to a change 
 14.25  in health plans, the health plan company must provide, upon 
 14.26  request, authorization to receive services that are otherwise 
 14.27  covered under the terms of the new health plan through the 
 14.28  enrollee's current provider for the remainder of the enrollee's 
 14.29  life if the enrollee has a medical prognosis of a terminal 
 14.30  condition with a life expectancy of 180 days or less as 
 14.31  determined by the enrollee's primary care provider or, if the 
 14.32  enrollee does not have such a medical prognosis, for up to 120 
 14.33  days if the enrollee is engaged in a current course of treatment 
 14.34  for one or more of the following conditions: 
 14.35     (1) an acute condition; 
 14.36     (2) a life-threatening mental or physical illness; 
 15.1      (3) pregnancy beyond the first trimester of pregnancy; or 
 15.2      (4) a disabling or chronic condition that is in an acute 
 15.3   phase.  
 15.4   For all requests for authorization under this paragraph, the 
 15.5   health plan company must grant the request for authorization 
 15.6   unless the enrollee does not meet the criteria provided in this 
 15.7   paragraph. 
 15.8      (b) The health plan company shall prepare a written plan 
 15.9   that provides a process for coverage determinations regarding 
 15.10  continuity of care of up to 120 days for new enrollees who 
 15.11  request continuity of care with their former provider, if the 
 15.12  new enrollee: 
 15.13     (1) is receiving culturally appropriate services and the 
 15.14  health plan company does not have a provider in its preferred 
 15.15  provider network with special expertise in the delivery of these 
 15.16  culturally appropriate services within the time and distance 
 15.17  requirements of section 62D.124, subdivision 1; or 
 15.18     (2) does not speak English and the health plan company does 
 15.19  not have a provider in its preferred provider network who can 
 15.20  communicate with the enrollee, either directly or through an 
 15.21  interpreter, within the time and distance requirements of 
 15.22  section 62D.124, subdivision 1. 
 15.23  The written plan must explain the criteria that will be used to 
 15.24  determine whether a need for continuity of care exists and how 
 15.25  it will be provided. 
 15.26     (c) This paragraph applies to requests under paragraph (a) 
 15.27  or (b).  The health plan company may require medical records and 
 15.28  other supporting documentation to be submitted with the request 
 15.29  for authorization.  The health plan company must explain the 
 15.30  criteria it used to make its decision on the request for 
 15.31  authorization.  If an authorization is granted, the health plan 
 15.32  company must explain how continuity of care will be provided.  
 15.33     (b) (d) This subdivision applies only to group coverage and 
 15.34  continuation and conversion coverage, and applies only to 
 15.35  changes in health plans made by the employer. 
 15.36     Subd. 2a.  [LIMITATIONS.] (a) Subdivisions 1 and 2 apply 
 16.1   only if the enrollee's health care provider agrees to: 
 16.2      (1) accept as payment in full the lesser of the health plan 
 16.3   company's reimbursement rate for in-network providers for the 
 16.4   same or similar service or the enrollee's health care provider's 
 16.5   regular fee for that service; 
 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) Nothing in this section requires a health plan company 
 16.11  to provide coverage for a health care service or treatment that 
 16.12  is not covered under the enrollee's health plan.  
 16.13     Subd. 3.  [DISCLOSURES DISCLOSURE.] The written plans 
 16.14  required under this section must be made available upon request 
 16.15  to enrollees or prospective enrollees.  Information regarding an 
 16.16  enrollee's rights under this section must be included in member 
 16.17  contracts or certificates of coverage and must be provided by a 
 16.18  health plan company upon request of an enrollee or prospective 
 16.19  enrollee.  
 16.20     Sec. 17.  Minnesota Statutes 1998, section 62Q.58, is 
 16.21  amended to read: 
 16.22     62Q.58 [ACCESS TO SPECIALTY CARE.] 
 16.23     Subdivision 1.  [STANDING REFERRAL.] A health plan company 
 16.24  shall establish a procedure by which an enrollee may apply 
 16.25  for and, if appropriate, receive a standing referral to a health 
 16.26  care provider who is a specialist if a referral to a specialist 
 16.27  is required for coverage.  This procedure for a standing 
 16.28  referral must specify the necessary criteria and conditions, 
 16.29  which must be met in order for an enrollee to obtain a standing 
 16.30  referral managed care review and approval an enrollee must 
 16.31  obtain before such a standing referral is permitted. 
 16.32     Subd. 1a.  [MANDATORY STANDING REFERRAL.] An enrollee who 
 16.33  requests a standing referral to a specialist qualified to treat 
 16.34  the specific condition described in clauses (1) to (5) must be 
 16.35  given a standing referral for visits to such a specialist if 
 16.36  benefits for such treatment are provided under the health plan 
 17.1   and the enrollee meets any of the following conditions:  
 17.2      (1) a chronic health condition that is in an acute phase; 
 17.3      (2) a life-threatening mental or physical illness; 
 17.4      (3) pregnancy beyond the first trimester of pregnancy; 
 17.5      (4) a degenerative disease or disability; or 
 17.6      (5) other condition or disease of sufficient seriousness 
 17.7   and complexity to require treatment by a specialist. 
 17.8      Subd. 2.  [COORDINATION OF SERVICES.] A primary care 
 17.9   provider or primary care group shall remain responsible for 
 17.10  coordinating the care of an enrollee who has received a standing 
 17.11  referral to a specialist.  The specialist shall not make any 
 17.12  secondary referrals related to primary care services without 
 17.13  prior approval by the primary care provider or primary care 
 17.14  group.  However, An enrollee with a standing referral to a 
 17.15  specialist may request primary care services from that 
 17.16  specialist.  The specialist, in agreement with the enrollee and 
 17.17  primary care provider or primary care group, may elect to 
 17.18  provide primary care services to that the enrollee, authorize 
 17.19  tests and services, and make secondary referrals according to 
 17.20  procedures established by the health plan company.  The health 
 17.21  plan company may limit the primary care services, tests and 
 17.22  services, and secondary referrals authorized under this 
 17.23  subdivision to those that are related to the specific condition 
 17.24  or conditions for which the standing referral was made. 
 17.25     Subd. 3.  [DISCLOSURE.] Information regarding referral 
 17.26  procedures must be included in member contracts or certificates 
 17.27  of coverage and must be provided to an enrollee or prospective 
 17.28  enrollee by a health plan company upon request. 
 17.29     Subd. 4.  [REFERRAL.] (a) If a standing referral is 
 17.30  authorized under subdivision 1 or is mandatory under subdivision 
 17.31  1a, the health plan company must provide a referral to an 
 17.32  appropriate participating specialist who is reasonably available 
 17.33  and accessible to provide the treatment or to a nonparticipating 
 17.34  specialist if the health plan company does not have an 
 17.35  appropriate participating specialist that is reasonably 
 17.36  available and accessible to treat the enrollee's condition or 
 18.1   disease. 
 18.2      (b) If an enrollee receives services from a 
 18.3   nonparticipating specialist because a participating specialist 
 18.4   is not available, services must be provided at no additional 
 18.5   cost to the enrollee beyond what the enrollee would otherwise 
 18.6   pay for services received from a participating specialist. 
 18.7      Sec. 18.  [QUALITY OF PATIENT CARE.] 
 18.8      The commissioner of health shall evaluate the feasibility 
 18.9   of collecting data on the quality of patient care provided in 
 18.10  hospitals, outpatient surgical centers, and other health care 
 18.11  facilities.  In this evaluation, the commissioner shall examine 
 18.12  the appropriate roles of the public and private sectors and the 
 18.13  need for risk adjusting data.  The evaluation must consider 
 18.14  mechanisms to identify the quality of nursing care provided to 
 18.15  consumers by examining variables such as skin breakdown and 
 18.16  patient injuries.  Any plan developed to collect data must also 
 18.17  address issues related to the release of this data in a useful 
 18.18  form to the public. 
 18.19     Sec. 19.  [FISCAL PROVISIONS.] 
 18.20     Any increased costs incurred by any state agency as a 
 18.21  result of this act must be absorbed internally by the state 
 18.22  agency within its appropriations and must not be treated as a 
 18.23  base adjustment for fiscal years 2002 and 2003. 
 18.24     Sec. 20.  [REPEALER.] 
 18.25     Minnesota Statutes 1998, sections 16B.93; 16B.94; 16B.95; 
 18.26  16B.96; and 62D.08, subdivision 5, are repealed. 
 18.27     Sec. 21.  [EFFECTIVE DATE.] 
 18.28     Sections 1, 4, 16, and 17 are effective for all policies, 
 18.29  contracts, or health benefit plans issued or renewed on or after 
 18.30  July 1, 2001.  Section 6 is effective January 1, 2001.