3rd Engrossment - 82nd Legislature (2001 - 2002) Posted on 12/15/2009 12:00am
1.1 A bill for an act 1.2 relating to health; providing patient protections; 1.3 amending Minnesota Statutes 2000, sections 45.027, 1.4 subdivision 6; 62D.17, subdivision 1; 62J.38; 62M.02, 1.5 subdivision 21; 62Q.56; and 62Q.58; proposing coding 1.6 for new law in Minnesota Statutes, chapter 62D. 1.7 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 1.8 Section 1. Minnesota Statutes 2000, section 45.027, 1.9 subdivision 6, is amended to read: 1.10 Subd. 6. [VIOLATIONS AND PENALTIES.] The commissioner may 1.11 impose a civil penalty not to exceed $10,000 per violation upon 1.12 a person who violates any law, rule, or order related to the 1.13 duties and responsibilities entrusted to the commissioner unless 1.14 a different penalty is specified. If a civil penalty is imposed 1.15 on a health carrier as defined in section 62A.011, the 1.16 commissioner must divide 50 percent of the amount among any 1.17 policy holders or certificate holders affected by the violation, 1.18 unless the commissioner certifies in writing that the division 1.19 and distribution to enrollees would be too administratively 1.20 complex or that the number of enrollees affected by the penalty 1.21 would result in a distribution of less than $50 per enrollee. 1.22 Sec. 2. [62D.109] [SERVICES ASSOCIATED WITH CLINICAL 1.23 TRIALS.] 1.24 A health maintenance contract shall cover a drug, device, 1.25 treatment, or procedure associated with a clinical trial if the 1.26 drug, device, treatment, or procedure is not deemed 2.1 experimental, investigative, or unproven in accordance with 2.2 Minnesota Rules, part 4685.0700, subpart 4, item F, and the 2.3 drug, device, treatment, or procedure would otherwise be covered 2.4 under the contract. 2.5 Sec. 3. Minnesota Statutes 2000, section 62D.17, 2.6 subdivision 1, is amended to read: 2.7 Subdivision 1. [ADMINISTRATIVE PENALTY.] The commissioner 2.8 of health may, for any violation of statute or rule applicable 2.9 to a health maintenance organization, or in lieu of suspension 2.10 or revocation of a certificate of authority under section 2.11 62D.15, levy an administrative penalty in an amount up to 2.12 $25,000 for each violation. In the case of contracts or 2.13 agreements made pursuant to section 62D.05, subdivisions 2 to 4, 2.14 each contract or agreement entered into or implemented in a 2.15 manner which violates sections 62D.01 to 62D.30 shall be 2.16 considered a separate violation. In determining the level of an 2.17 administrative penalty, the commissioner shall consider the 2.18 following factors: 2.19 (1) the number of enrollees affected by the violation; 2.20 (2) the effect of the violation on enrollees' health and 2.21 access to health services; 2.22 (3) if only one enrollee is affected, the effect of the 2.23 violation on that enrollee's health; 2.24 (4) whether the violation is an isolated incident or part 2.25 of a pattern of violations; and 2.26 (5) the economic benefits derived by the health maintenance 2.27 organization or a participating provider by virtue of the 2.28 violation. 2.29 Reasonable notice in writing to the health maintenance 2.30 organization shall be given of the intent to levy the penalty 2.31 and the reasons therefor, and the health maintenance 2.32 organization may have 15 days within which to file a written 2.33 request for an administrative hearing and review of the 2.34 commissioner of health's determination. Such administrative 2.35 hearing shall be subject to judicial review pursuant to chapter 2.36 14. If an administrative penalty is levied, the commissioner 3.1 must divide 50 percent of the amount among any enrollees 3.2 affected by the violation, unless the commissioner certifies in 3.3 writing that the division and distribution to enrollees would be 3.4 too administratively complex or that the number of enrollees 3.5 affected by the penalty would result in a distribution of less 3.6 than $50 per enrollee. 3.7 Sec. 4. Minnesota Statutes 2000, section 62J.38, is 3.8 amended to read: 3.9 62J.38 [COST CONTAINMENT DATA FROM GROUP PURCHASERS.] 3.10 (a) The commissioner shall require group purchasers to 3.11 submit detailed data on total health care spending for each 3.12 calendar year. Group purchasers shall submit data for the 1993 3.13 calendar year by April 1, 1994, and each April 1 thereafter 3.14 shall submit data for the preceding calendar year. 3.15 (b) The commissioner shall require each group purchaser to 3.16 submit data on revenue, expenses, and member months, as 3.17 applicable. Revenue data must distinguish between premium 3.18 revenue and revenue from other sources and must also include 3.19 information on the amount of revenue in reserves and changes in 3.20 reserves. Expenditure data, including raw data from claims, may3.21 must distinguish between costs incurred for patient care and 3.22 administrative costs. Patient care and administrative costs 3.23 must include only expenses incurred on behalf of health plan 3.24 members, and must not include the cost of providing health care 3.25 services for nonmembers at facilities owned by the group 3.26 purchaser or affiliate. Expenditure data must be provided 3.27 separately for the following categoriesorand for other 3.28 categories required by the commissioner: physician services, 3.29 dental services, other professional services, inpatient hospital 3.30 services, outpatient hospital services, emergency, pharmacy 3.31 services and other nondurable medical goods, mental health, and 3.32 chemical dependency services, other expenditures, subscriber 3.33 liability, and administrative costs. Administrative costs must 3.34 include costs for marketing; advertising; overhead; salaries and 3.35 benefits of central office staff who do not provide direct 3.36 patient care; underwriting; lobbying; claims processing; 4.1 provider contracting and credentialing; detection and prevention 4.2 of payment for fraudulent or unjustified requests for 4.3 reimbursement or services; clinical quality assurance and other 4.4 types of medical care quality improvement efforts; concurrent or 4.5 prospective utilization review as defined in section 62M.02; 4.6 costs incurred to acquire a hospital, clinic, or health care 4.7 facility, or the assets thereof; capital costs incurred on 4.8 behalf of a hospital or clinic; lease payments; or any other 4.9 costs incurred pursuant to a partnership, joint venture, 4.10 integration, or affiliation agreement with a hospital, clinic, 4.11 or other health care provider. The reports of this data must 4.12 also separately identify expenses for local, state, and federal 4.13 taxes, fees, and assessments. The commissioner may require each 4.14 group purchaser to submit any other data, including data in 4.15 unaggregated form, for the purposes of developing spending 4.16 estimates, setting spending limits, and monitoring actual 4.17 spending and costs. In addition to reporting administrative 4.18 costs incurred to acquire a hospital, clinic, or health care 4.19 facility, or the assets thereof; or any other costs incurred 4.20 pursuant to a partnership, joint venture, integration, or 4.21 affiliation agreement with a hospital, clinic, or other health 4.22 care provider; reports submitted under this section also must 4.23 include the payments made during the calendar year for these 4.24 purposes. The commissioner shall make public by group purchaser 4.25 data collected under this paragraph in accordance with section 4.26 62J.321, subdivision 5, paragraph (e). 4.27 (c) The commissioner may collect information on: 4.28 (1) premiums, benefit levels, managed care procedures, and 4.29 other features of health plan companies; 4.30 (2) prices, provider experience, and other information for 4.31 services less commonly covered by insurance or for which 4.32 patients commonly face significant out-of-pocket expenses; and 4.33 (3) information on health care services not provided 4.34 through health plan companies, including information on prices, 4.35 costs, expenditures, and utilization. 4.36 (d) All group purchasers shall provide the required data 5.1 using a uniform format and uniform definitions, as prescribed by 5.2 the commissioner. 5.3 Sec. 5. Minnesota Statutes 2000, section 62M.02, 5.4 subdivision 21, is amended to read: 5.5 Subd. 21. [UTILIZATION REVIEW ORGANIZATION.] "Utilization 5.6 review organization" means an entity including but not limited 5.7 to an insurance company licensed under chapter 60A to offer, 5.8 sell, or issue a policy of accident and sickness insurance as 5.9 defined in section 62A.01; a health service plan licensed under 5.10 chapter 62C; a health maintenance organization licensed under 5.11 chapter 62D; a community integrated service network licensed 5.12 under chapter 62N; an accountable provider network operating 5.13 under chapter 62T; a fraternal benefit society operating under 5.14 chapter 64B; a joint self-insurance employee health plan 5.15 operating under chapter 62H; a multiple employer welfare 5.16 arrangement, as defined in section 3 of the Employee Retirement 5.17 Income Security Act of 1974 (ERISA), United States Code, title 5.18 29, section 1103, as amended; a third party administrator 5.19 licensed under section 60A.23, subdivision 8, which conducts 5.20 utilization review and determines certification of an admission, 5.21 extension of stay, or other health care services for a Minnesota 5.22 resident; or any entity performing utilization review that is 5.23 affiliated with, under contract with, or conducting utilization 5.24 review on behalf of, a business entity in this state. 5.25 Utilization review organization does not include a clinic or 5.26 health care system acting pursuant to a written delegation 5.27 agreement with an otherwise regulated utilization review 5.28 organization that contracts with the clinic or health care 5.29 system. The regulated utilization review organization is 5.30 accountable for the delegated utilization review activities of 5.31 the clinic or health care system. 5.32 Sec. 6. Minnesota Statutes 2000, section 62Q.56, is 5.33 amended to read: 5.34 62Q.56 [CONTINUITY OF CARE.] 5.35 Subdivision 1. [CHANGE IN HEALTH CARE PROVIDER; GENERAL 5.36 NOTIFICATION.] (a) If enrollees are required to access services 6.1 through selected primary care providers for coverage, the health 6.2 plan company shall prepare a written plan that provides for 6.3 continuity of care in the event of contract termination between 6.4 the health plan company and any of the contracted primary care 6.5 providers, specialists, or general hospital providers. The 6.6 written plan must explain: 6.7 (1) how the health plan company will inform affected 6.8 enrollees, insureds, or beneficiariesabout termination at least 6.9 30 days before the termination is effective, if the health plan 6.10 company or health care network cooperative has received at least 6.11 120 days' prior notice; 6.12 (2) how the health plan company will inform the affected 6.13 enrollees about what other participating providers are available 6.14 to assume care and how it will facilitate an orderly transfer of 6.15 its enrollees from the terminating provider to the new provider 6.16 to maintain continuity of care; 6.17 (3) the procedures by which enrollees will be transferred 6.18 to other participating providers, when special medical needs, 6.19 special risks, or other special circumstances, such as cultural 6.20 or language barriers, require them to have a longer transition 6.21 period or be transferred to nonparticipating providers; 6.22 (4) who will identify enrollees with special medical needs 6.23 or at special risk and what criteria will be used for this 6.24 determination; and 6.25 (5) how continuity of care will be provided for enrollees 6.26 identified as having special needs or at special risk, and 6.27 whether the health plan company has assigned this responsibility 6.28 to its contracted primary care providers. 6.29 (b)If the contract termination was not for cause,6.30enrollees can request a referral to the terminating provider for6.31up to 120 days if they have special medical needs or have other6.32special circumstances, such as cultural or language barriers.6.33The health plan company can require medical records and other6.34supporting documentation in support of the requested referral.6.35Each request for referral to a terminating provider shall be6.36considered by the health plan company on a case-by-case7.1basis.For purposes of this section, contract termination 7.2 includes nonrenewal. 7.3(c) If the contract termination was for cause, enrollees7.4must be notified of the change and transferred to participating7.5providers in a timely manner so that health care services remain7.6available and accessible to the affected enrollees. The health7.7plan company is not required to refer an enrollee back to the7.8terminating provider if the termination was for cause.7.9 Subd. 1a. [CHANGE IN HEALTH CARE PROVIDER; TERMINATION NOT 7.10 FOR CAUSE.] (a) If the contract termination was not for cause 7.11 and the contract was terminated by the health plan company, the 7.12 health plan company must provide the terminated provider and all 7.13 enrollees being treated by that provider with notification of 7.14 the enrollees' rights to continuity of care with the terminated 7.15 provider. 7.16 (b) The health plan company must provide, upon request, 7.17 authorization to receive services that are otherwise covered 7.18 under the terms of the health plan through the enrollee's 7.19 current provider: 7.20 (1) for up to 120 days if the enrollee is engaged in a 7.21 current course of treatment for one or more of the following 7.22 conditions: 7.23 (i) an acute condition; 7.24 (ii) a life-threatening mental or physical illness; 7.25 (iii) pregnancy beyond the first trimester of pregnancy; 7.26 (iv) a physical or mental disability defined as an 7.27 inability to engage in one or more major life activities, 7.28 provided that the disability has lasted or can be expected to 7.29 last for at least a year, or can be expected to result in death; 7.30 or 7.31 (v) a disabling or chronic condition that is in an acute 7.32 phase; or 7.33 (2) for the rest of the enrollee's life if a physician 7.34 certifies that the enrollee has an expected lifetime of 180 days 7.35 or less. 7.36 For all requests for authorization to receive services under 8.1 this paragraph, the health plan company must grant the request 8.2 unless the enrollee does not meet the criteria provided in this 8.3 paragraph. 8.4 (c) The health plan company shall prepare a written plan 8.5 that provides a process for coverage determinations regarding 8.6 continuity of care of up to 120 days for enrollees who request 8.7 continuity of care with their former provider, if the enrollee: 8.8 (1) is receiving culturally appropriate services and the 8.9 health plan company does not have a provider in its preferred 8.10 provider network with special expertise in the delivery of those 8.11 culturally appropriate services within the time and distance 8.12 requirements of section 62D.124, subdivision 1; or 8.13 (2) does not speak English and the health plan company does 8.14 not have a provider in its preferred provider network who can 8.15 communicate with the enrollee, either directly or through an 8.16 interpreter, within the time and distance requirements of 8.17 section 62D.124, subdivision 1. 8.18 The written plan must explain the criteria that will be used to 8.19 determine whether a need for continuity of care exists and how 8.20 it will be provided. 8.21 Subd. 1b. [CHANGE IN HEALTH CARE PROVIDER; TERMINATION FOR 8.22 CAUSE.] If the contract termination was for cause, enrollees 8.23 must be notified of the change and transferred to participating 8.24 providers in a timely manner so that health care services remain 8.25 available and accessible to the affected enrollees. The health 8.26 plan company is not required to refer an enrollee back to the 8.27 terminating provider if the termination was for cause. 8.28 Subd. 2. [CHANGE IN HEALTH PLANS.] (a)The health plan8.29company shall prepare a written plan that provides a process for8.30coverage determinations for continuity of care for new enrollees8.31with special needs, special risks, or other special8.32circumstances, such as cultural or language barriers, who8.33request continuity of care with their former provider for up to8.34120 days. The written plan must explain the criteria that will8.35be used for determining special needs cases, and how continuity8.36of care will be provided.If an enrollee is subject to a change 9.1 in health plans, the enrollee's new health plan company must 9.2 provide, upon request, authorization to receive services that 9.3 are otherwise covered under the terms of the new health plan 9.4 through the enrollee's current provider: 9.5 (1) for up to 120 days if the enrollee is engaged in a 9.6 current course of treatment for one or more of the following 9.7 conditions: 9.8 (i) an acute condition; 9.9 (ii) a life-threatening mental or physical illness; 9.10 (iii) pregnancy beyond the first trimester of pregnancy; 9.11 (iv) a physical or mental disability defined as an 9.12 inability to engage in one or more major life activities, 9.13 provided that the disability has lasted or can be expected to 9.14 last for at least a year, or can be expected to result in death; 9.15 or 9.16 (v) a disabling or chronic condition that is in an acute 9.17 phase; or 9.18 (2) for the rest of the enrollee's life if a physician 9.19 certifies that the enrollee has an expected lifetime of 180 days 9.20 or less. 9.21 For all requests for authorization under this paragraph, the 9.22 health plan company must grant the request for authorization 9.23 unless the enrollee does not meet the criteria provided in this 9.24 paragraph. 9.25 (b) The health plan company shall prepare a written plan 9.26 that provides a process for coverage determinations regarding 9.27 continuity of care of up to 120 days for new enrollees who 9.28 request continuity of care with their former provider, if the 9.29 new enrollee: 9.30 (1) is receiving culturally appropriate services and the 9.31 health plan company does not have a provider in its preferred 9.32 provider network with special expertise in the delivery of those 9.33 culturally appropriate services within the time and distance 9.34 requirements of section 62D.124, subdivision 1; or 9.35 (2) does not speak English and the health plan company does 9.36 not have a provider in its preferred provider network who can 10.1 communicate with the enrollee, either directly or through an 10.2 interpreter, within the time and distance requirements of 10.3 section 62D.124, subdivision 1. 10.4 The written plan must explain the criteria that will be used to 10.5 determine whether a need for continuity of care exists and how 10.6 it will be provided. 10.7(b)(c) This subdivision applies only to group coverage and 10.8 continuation and conversion coverage, and applies only to 10.9 changes in health plans made by the employer. 10.10 Subd. 2a. [LIMITATIONS.] (a) Subdivisions 1, 1a, 1b, and 2 10.11 apply only if the enrollee's health care provider agrees to: 10.12 (1) accept as payment in full the lesser of the health plan 10.13 company's reimbursement rate for in-network providers for the 10.14 same or similar service or the enrollee's health care provider's 10.15 regular fee for that service; 10.16 (2) adhere to the health plan company's preauthorization 10.17 requirements; and 10.18 (3) provide the health plan company with all necessary 10.19 medical information related to the care provided to the enrollee. 10.20 (b) Nothing in this section requires a health plan company 10.21 to provide coverage for a health care service or treatment that 10.22 is not covered under the enrollee's health plan. 10.23 Subd. 2b. [REQUEST FOR AUTHORIZATION.] The health plan 10.24 company may require medical records and other supporting 10.25 documentation to be submitted with the requests for 10.26 authorization made under subdivision 1, 1a, 1b, or 2. If the 10.27 authorization is denied, the health plan company must explain 10.28 the criteria it used to make its decision on the request for 10.29 authorization. If the authorization is granted, the health plan 10.30 company must explain how continuity of care will be provided. 10.31 Subd. 3. [DISCLOSURESDISCLOSURE.]The written plans10.32required under this section must be made available upon request10.33to enrollees or prospective enrolleesInformation regarding an 10.34 enrollee's rights under this section must be included in member 10.35 contracts or certificates of coverage and must be provided by a 10.36 health plan company upon request of an enrollee or prospective 11.1 enrollee. 11.2 Sec. 7. Minnesota Statutes 2000, section 62Q.58, is 11.3 amended to read: 11.4 62Q.58 [ACCESS TO SPECIALTY CARE.] 11.5 Subdivision 1. [STANDING REFERRAL.] A health plan company 11.6 shall establish a procedure by which an enrollee may apply 11.7 for and, if appropriate, receive a standing referral to a health 11.8 care provider who is a specialist if a referral to a specialist 11.9 is required for coverage. This procedure for a standing 11.10 referral must specify the necessarycriteria and conditions,11.11which must be met in order for an enrollee to obtain a standing11.12referralmanaged care review and approval an enrollee must 11.13 obtain before such a standing referral is permitted. 11.14 Subd. 1a. [MANDATORY STANDING REFERRAL.] An enrollee who 11.15 requests a standing referral to a specialist qualified to treat 11.16 the specific condition described in clauses (1) to (5) must be 11.17 given a standing referral for visits to such a specialist if 11.18 benefits for such treatment are provided under the health plan 11.19 and the enrollee has any of the following conditions: 11.20 (1) a chronic health condition; 11.21 (2) a life-threatening mental or physical illness; 11.22 (3) pregnancy beyond the first trimester of pregnancy; 11.23 (4) a degenerative disease or disability; or 11.24 (5) any other condition or disease of sufficient 11.25 seriousness and complexity to require treatment by a specialist. 11.26 Nothing in this section limits the application of section 11.27 62Q.52 specifying direct access to obstetricians and 11.28 gynecologists. 11.29 Subd. 2. [COORDINATION OF SERVICES.]A primary care11.30provider or primary care group shall remain responsible for11.31coordinating the care of an enrollee who has received a standing11.32referral to a specialist. The specialist shall not make any11.33secondary referrals related to primary care services without11.34prior approval by the primary care provider or primary care11.35group. However,An enrollee with a standing referral to a 11.36 specialist may request primary care services from that 12.1 specialist. The specialist, in agreement with the enrollee and 12.2 primary care provider or primary care group, may elect to 12.3 provide primary care services tothatthe enrollee, authorize 12.4 tests and services, and make secondary referrals according to 12.5 procedures established by the health plan company. The health 12.6 plan company may limit the primary care services, tests and 12.7 services, and secondary referrals authorized under this 12.8 subdivision to those that are related to the specific condition 12.9 or conditions for which the standing referral was made. 12.10 Subd. 3. [DISCLOSURE.] Information regarding referral 12.11 procedures must be included in member contracts or certificates 12.12 of coverage and must be provided to an enrollee or prospective 12.13 enrollee by a health plan company upon request. 12.14 Subd. 4. [REFERRAL.] (a) If a standing referral is 12.15 authorized under subdivision 1 or is mandatory under subdivision 12.16 1a, the health plan company must provide a referral to an 12.17 appropriate participating specialist who is reasonably available 12.18 and accessible to provide the treatment or to a nonparticipating 12.19 specialist if the health plan company does not have an 12.20 appropriate participating specialist who is reasonably available 12.21 and accessible to treat the enrollee's condition or disease. 12.22 (b) If an enrollee receives services from a 12.23 nonparticipating specialist because a participating specialist 12.24 is not available, services must be provided at no additional 12.25 cost to the enrollee beyond what the enrollee would otherwise 12.26 pay for services received from a participating specialist. 12.27 Sec. 8. [COVERAGE OF CLINICAL TRIALS.] 12.28 The commissioners of health and commerce shall, in 12.29 consultation with the commissioner of employee relations, 12.30 convene a work group to study health plan coverage of clinical 12.31 trials. The work group shall be made up of representatives of 12.32 consumers, patient advocates, health plan companies, purchasers, 12.33 providers, and other health care professionals involved in the 12.34 care and treatment of patients. The work group shall consider 12.35 definitions of routine patient costs, protocol-induced costs, 12.36 and high-quality clinical trials. The work group shall also 13.1 consider guidelines for voluntary agreements for health plan 13.2 coverage of routine patient costs incurred by patients 13.3 participating in high-quality clinical trials. The commissioner 13.4 shall submit the findings and the recommendations of the work 13.5 group to the chairs of the health policy and finance committees 13.6 in the senate and the house by January 15, 2002. 13.7 [EFFECTIVE DATE.] This section is effective the day 13.8 following final enactment. 13.9 Sec. 9. [QUALITY OF PATIENT CARE.] 13.10 The commissioner of health shall evaluate the feasibility 13.11 of collecting data on the quality of patient care provided in 13.12 hospitals, outpatient surgical centers, and other health care 13.13 facilities. In the evaluation, the commissioner shall examine 13.14 the appropriate roles of the public and private sectors and the 13.15 need for risk-adjusting data. The evaluation must consider 13.16 mechanisms to identify the quality of nursing care provided to 13.17 consumers by examining variables such as skin breakdown and 13.18 patient injuries. Any plan developed to collect data must also 13.19 address issues related to the release of the data in a useful 13.20 form to the public. The commissioner shall prepare and 13.21 distribute a written report of the evaluation by January 15, 13.22 2002. 13.23 Sec. 10. [EFFECTIVE DATE.] 13.24 Sections 1 and 3 are effective for violations committed on 13.25 or after August 1, 2001. Section 4 is effective beginning with 13.26 the report for the 2001 calendar year. Sections 2, 5, and 9 are 13.27 effective the day following final enactment. Sections 6 and 7 13.28 are effective January 1, 2002, and apply to health plans issued 13.29 or renewed on or after that date.