SF 1358

as introduced - 87th Legislature (2011 - 2012) Posted on 02/23/2012 09:46am

A bill for an act
relating to commerce; making changes to health plan requirements; amending
Minnesota Statutes 2010, sections 43A.23, subdivision 1; 43A.317, subdivision
6; 62A.03, subdivision 1; 62A.047; 62A.17, subdivision 2; 62A.21, subdivisions
2a, 2b; 62A.25, subdivision 2; 62A.302; 62A.615; 62A.65, subdivisions 5, 6;
62C.14, subdivision 5; 62D.07, subdivision 3; 62D.105; 62E.06, subdivision 1;
62L.02, subdivisions 11, 14a, 19; 62L.03, subdivision 4; 62L.05, subdivision
9; 62Q.01, by adding subdivisions; 62Q.021; 62Q.23; 62Q.43, subdivision
2; 62Q.52; 62Q.55; 62Q.68, subdivision 1; 62Q.69, subdivision 3; 62Q.70,
subdivision 1; 62Q.71; 62Q.73; 62Q.80, subdivision 2; 471.61, subdivision
1a; proposing coding for new law in Minnesota Statutes, chapters 62Q; 72A;
repealing Minnesota Statutes 2010, section 62E.02, subdivision 7.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2010, section 43A.23, subdivision 1, is amended to read:

Subdivision 1.

General.

(a) The commissioner is authorized to request proposals
or to negotiate and to enter into contracts with parties which in the judgment of the
commissioner are best qualified to provide service to the benefit plans. Contracts entered
into are not subject to the requirements of sections 16C.16 to 16C.19. The commissioner
may negotiate premium rates and coverage. The commissioner shall consider the cost of
the plans, conversion options relating to the contracts, service capabilities, character,
financial position, and reputation of the carriers, and any other factors which the
commissioner deems appropriate. Each benefit contract must be for a uniform term of at
least one year, but may be made automatically renewable from term to term in the absence
of notice of termination by either party. A carrier licensed under chapter 62A is exempt
from the taxes imposed by chapter 297I on premiums paid to it by the state.

(b) All self-insured hospital and medical service products must comply with coverage
mandates, data reporting, and consumer protection requirements applicable to the licensed
carrier administering the product, had the product been insured, including chapters 62J,
62M, and 62Q. Any self-insured products that limit coverage to a network of providers
or provide different levels of coverage between network and nonnetwork providers shall
comply with section 62D.123 and geographic access standards for health maintenance
organizations adopted by the commissioner of health in rule under chapter 62D.

(c) Notwithstanding paragraph (b), a self-insured hospital and medical product
offered under sections 43A.22 to 43A.30 is deleted text begin not deleted text end required to extend dependent coverage
to an eligible employee's deleted text begin unmarried deleted text end child deleted text begin under the age of 25 deleted text end to the full extent required
under chapters 62A and 62L. Dependent new text begin child new text end coverage must, at a minimum, extend to an
eligible employee's deleted text begin unmarried deleted text end new text begin dependent new text end child deleted text begin who is under the age of 19 or an unmarried
child under the age of 25 who is a full-time student. A person who is at least 19 years of
age but who is under the age of 25 and who is not a full-time student must be permitted
to be enrolled as a dependent of an eligible employee until age 25 if the person: deleted text end new text begin to the
limiting age as defined in section 62Q.01, subdivision 7.
new text end

deleted text begin (1) was a full-time student immediately prior to being ordered into active military
service, as defined in section 190.05, subdivision 5b or 5c;
deleted text end

deleted text begin (2) has been separated or discharged from active military service; and
deleted text end

deleted text begin (3) would be eligible to enroll as a dependent of an eligible employee, except that
the person is not a full-time student.
deleted text end

deleted text begin The definition of "full-time student" for purposes of this paragraph includes any student
who by reason of illness, injury, or physical or mental disability as documented by
a physician is unable to carry what the educational institution considers a full-time
course load so long as the student's course load is at least 60 percent of what otherwise
is considered by the institution to be a full-time course load. Any notice regarding
termination of coverage due to attainment of the limiting age must include information
about this definition of "full-time student."
deleted text end

(d) Beginning January 1, 2010, the health insurance benefit plans offered in the
commissioner's plan under section 43A.18, subdivision 2, and the managerial plan under
section 43A.18, subdivision 3, must include an option for a health plan that is compatible
with the definition of a high-deductible health plan in section 223 of the United States
Internal Revenue Code.

Sec. 2.

Minnesota Statutes 2010, section 43A.317, subdivision 6, is amended to read:

Subd. 6.

Individual eligibility.

(a) Procedures. The commissioner shall establish
procedures for eligible employees and other eligible individuals to apply for coverage
through the program.

(b) Employees. An employer shall determine when it applies to the program the
criteria its employees must meet to be eligible for coverage under its plan. An employer
may subsequently change the criteria annually or at other times with approval of the
commissioner. The criteria must provide that new employees become eligible for coverage
after a probationary period of at least 30 days, but no more than 90 days.

(c) Other individuals. An employer may elect to cover under its plan:

(1) the spouse, dependent children new text begin to the limiting age as defined in section 62Q.01,
subdivision 7 new text end , and dependent grandchildren of a covered employee;

(2) a retiree who is eligible to receive a pension or annuity from the employer and a
covered retiree's spouse, dependent children new text begin to the limiting age as defined in section
62Q.01, subdivision 7 new text end , and dependent grandchildren;

(3) the surviving spouse, dependent children, and dependent grandchildren of a
deceased employee or retiree, if the spouse, children, or grandchildren were covered
at the time of the death;

(4) a covered employee who becomes disabled, as provided in sections 62A.147
and 62A.148; or

(5) any other categories of individuals for whom group coverage is required by
state or federal law.

An employer shall determine when it applies to the program the criteria individuals
in these categories must meet to be eligible for coverage. An employer may subsequently
change the criteria annually, or at other times with approval of the commissioner. The
criteria for dependent children new text begin to the limiting age as defined in section 62Q.01, subdivision
7, new text end and dependent grandchildren may be no more inclusive than the criteria under section
43A.18, subdivision 2. This paragraph shall not be interpreted as relieving the program
from compliance with any federal and state continuation of coverage requirements.

(d) Waiver and late entrance. An eligible individual may waive coverage at the
time the employer joins the program or when coverage first becomes available. The
commissioner may establish a preexisting condition exclusion of not more than 18 months
for late entrants as defined in section 62L.02, subdivision 19.

(e) Continuation coverage. The program shall provide all continuation coverage
required by state and federal law.

Sec. 3.

Minnesota Statutes 2010, section 62A.03, subdivision 1, is amended to read:

Subdivision 1.

Conditions.

No policy of individual accident and sickness insurance
may be delivered or issued for delivery to a person in this state unless:

(1) Premium. The entire money and other considerations therefor are expressed
therein.

(2) Time effective. The time at which the insurance takes effect and terminates is
expressed therein.

(3) One person. It purports to insure only one person, except that a policy may
insure, originally or by subsequent amendment, upon the application of an adult member
of a family deemed the policyholder, any two or more eligible members of that family,
including:

(a) husband,

(b) wife,

(c) dependent children new text begin to the limiting age as defined in section 62Q.01, subdivision
7 new text end , new text begin or
new text end

deleted text begin (d) any children under a specified age of 19 years or less, or
deleted text end

deleted text begin (e) deleted text end new text begin (d) new text end any other person dependent upon the policyholder.

(4) Appearance. The style, arrangement, and overall appearance of the policy give
no undue prominence to any portion of the text and every printed portion of the text of the
policy and of any endorsements or attached papers is plainly printed in light-face type
of a style in general use. The type size must be uniform and not less than ten point with
a lowercase unspaced alphabet length not less than 120 point. The "text" includes all
printed matter except the name and address of the insurer, name or title of the policy, the
brief description, if any, the reference to renewal or cancellation by a separate statement,
if any, and the captions and subcaptions.

(5) Description of policy. The policy, on the first page, indicates or refers to its
provisions for renewal or cancellation either in the brief description, if any, or by a separate
statement printed in type not smaller than the type used for captions or a separate provision
bearing a caption which accurately describes the renewability or cancelability of the policy.

(6) Exceptions in policy. The exceptions and reductions of indemnity are set
forth in the policy and, except those which are set forth in section 62A.04, printed, at
the insurer's option, either with the benefit provision to which they apply, or under an
appropriate caption such as "EXCEPTIONS" or "EXCEPTIONS AND REDUCTIONS."
However, if an exception or reduction specifically applies only to a particular benefit of
the policy, a statement of the exception or reduction must be included with the benefit
provision to which it applies.

(7) Form number. Each form, including riders and endorsements, is identified by a
form number in the lower left hand corner of the first page thereof.

(8) No incorporation by reference. It contains no provision purporting to make
any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy
unless the portion is set forth in full in the policy, except in the case of the incorporation
of, or reference to, a statement of rates, classification of risks, or short rate table filed
with the commissioner.

(9) Medical benefits. If the policy contains a provision for medical expense benefits,
the term "medical benefits" or similar terms as used therein includes treatments by all
licensed practitioners of the healing arts unless, subject to the qualifications contained in
clause (10), the policy specifically states the practitioners whose services are covered.

(10) Osteopath, optometrist, chiropractor, or registered nurse services. With
respect to any policy of individual accident and sickness insurance issued or entered
into subsequent to August 1, 1974, notwithstanding the provisions of the policy, if it
contains a provision providing for reimbursement for any service which is in the lawful
scope of practice of a duly licensed osteopath, optometrist, chiropractor, or registered
nurse meeting the requirements of section 62A.15, subdivision 3a, the person entitled to
benefits or person performing services under the policy is entitled to reimbursement on an
equal basis for the service, whether the service is performed by a physician, osteopath,
optometrist, chiropractor, or registered nurse meeting the requirements of section 62A.15,
subdivision 3a, licensed under the laws of this state.

Sec. 4.

Minnesota Statutes 2010, section 62A.047, is amended to read:

62A.047 CHILDREN'S HEALTH SUPERVISION SERVICES AND
PRENATAL CARE SERVICES.

A policy of individual or group health and accident insurance regulated under this
chapter, or individual or group subscriber contract regulated under chapter 62C, health
maintenance contract regulated under chapter 62D, or health benefit certificate regulated
under chapter 64B, issued, renewed, or continued to provide coverage to a Minnesota
resident, must provide coverage for child health supervision services and prenatal care
services. The policy, contract, or certificate must specifically exempt reasonable and
customary charges for child health supervision services and prenatal care services from a
deductible, co-payment, or other coinsurance or dollar limitation requirement. new text begin Nothing
in this section prohibits a health plan company that has a network of providers from
imposing a deductible, co-payment, or other coinsurance or dollar limitation requirement
for child health supervision services and prenatal care services that are delivered by an
out-of-network provider. new text end This section does not prohibit the use of policy waiting periods
deleted text begin or preexisting condition limitations deleted text end for these services. Minimum benefits may be limited
to one visit payable to one provider for all of the services provided at each visit cited in
this section subject to the schedule set forth in this section. deleted text begin Nothing in this section applies
to a commercial health insurance policy issued as a companion to a health maintenance
organization contract, a policy designed primarily to provide coverage payable on a
per diem, fixed indemnity, or nonexpense incurred basis, or a policy that provides
only accident coverage. deleted text end new text begin Nothing in this section prevents a health plan company from
using reasonable medical management techniques to determine the frequency, method,
treatment, or setting for child health supervision services and prenatal care services.
new text end

new text begin A policy, contract, or certificate described under this section may not apply
preexisting condition limitations to individuals under 19 years of age. This paragraph
does not apply to individual coverage that is grandfathered plan coverage, as defined
in section 62Q.01, subdivision 9.
new text end

"Child health supervision services" means pediatric preventive services, appropriate
immunizations, developmental assessments, and laboratory services appropriate to the age
of a child from birth to age six, and appropriate immunizations from ages six to 18, as
defined by Standards of Child Health Care issued by the American Academy of Pediatrics.
Reimbursement must be made for at least five child health supervision visits from birth
to 12 months, three child health supervision visits from 12 months to 24 months, once a
year from 24 months to 72 months.

"Prenatal care services" means the comprehensive package of medical and
psychosocial support provided throughout the pregnancy, including risk assessment,
serial surveillance, prenatal education, and use of specialized skills and technology,
when needed, as defined by Standards for Obstetric-Gynecologic Services issued by the
American College of Obstetricians and Gynecologists.

Sec. 5.

Minnesota Statutes 2010, section 62A.17, subdivision 2, is amended to read:

Subd. 2.

Responsibility of employee.

Every covered employee electing to continue
coverage shall pay the former employer, on a monthly basis, the cost of the continued
coverage. The policy, contract, or plan must require the group policyholder or contract
holder to, upon request, provide the employee with written verification from the insurer
of the cost of this coverage promptly at the time of eligibility for this coverage and at
any time during the continuation period. If the policy, contract, or health care plan is
administered by a trust, every covered employee electing to continue coverage shall pay
the trust the cost of continued coverage according to the eligibility rules established by the
trust. In no event shall the amount of premium charged exceed 102 percent of the cost
to the plan for such period of coverage for similarly situated employees with respect to
whom neither termination nor layoff has occurred, without regard to whether such cost
is paid by the employer or employee. The employee shall be eligible to continue the
coverage until the employee becomes covered under another group health plan, or for a
period of 18 months after the termination of or lay off from employment, whichever is
shorter. new text begin For an individual age 19 or older, new text end if the employee becomes covered under another
group policy, contract, or health plan and the new group policy, contract, or health plan
contains any preexisting condition limitations, the employee may, subject to the 18-month
maximum continuation limit, continue coverage with the former employer until the
preexisting condition limitations have been satisfied. The new policy, contract, or health
plan is primary except as to the preexisting condition. In the case of a newborn child who
is a dependent of the employee, the new policy, contract, or health plan is primary upon
the date of birth of the child, regardless of which policy, contract, or health plan coverage
is deemed primary for the mother of the child.

Sec. 6.

Minnesota Statutes 2010, section 62A.21, subdivision 2a, is amended to read:

Subd. 2a.

Continuation privilege.

Every policy described in subdivision 1 shall
contain a provision which permits continuation of coverage under the policy for the
insured's former spouse and dependent children deleted text begin upon deleted text end new text begin to the limiting age as defined
in section 62Q.01, subdivision 7, who were covered on the day before new text end entry of a valid
decree of dissolution of marriage. The coverage shall be continued until the earlier of
the following dates:

(a) the date the insured's former spouse becomes covered under any other group
health plan; or

(b) the date coverage would otherwise terminate under the policy.

If the coverage is provided under a group policy, any required premium contributions
for the coverage shall be paid by the insured on a monthly basis to the group policyholder
for remittance to the insurer. The policy must require the group policyholder to, upon
request, provide the insured with written verification from the insurer of the cost of this
coverage promptly at the time of eligibility for this coverage and at any time during the
continuation period. In no event shall the amount of premium charged exceed 102 percent
of the cost to the plan for such period of coverage for other similarly situated spouses and
dependent children new text begin to the limiting age as defined in section 62Q.01, subdivision 7, new text end with
respect to whom the marital relationship has not dissolved, without regard to whether such
cost is paid by the employer or employee.

Upon request by the insured's former spouse or dependent child new text begin to the limiting age
as defined in section 62Q.01, subdivision 7, who was covered on the day before entry of
a valid decree of dissolution new text end , a health carrier must provide the instructions necessary to
enable the child or former spouse to elect continuation of coverage.

Sec. 7.

Minnesota Statutes 2010, section 62A.21, subdivision 2b, is amended to read:

Subd. 2b.

Conversion privilege.

Every policy described in subdivision 1 shall
contain a provision allowing a former spouse and dependent children new text begin to the limiting age
as defined in section 62Q.01, subdivision 7, new text end of an insured new text begin who were covered on the day
before entry of a valid decree of dissolution new text end , without providing evidence of insurability, to
obtain from the insurer at the expiration of any continuation of coverage required under
subdivision 2a or sections 62A.146 and 62A.20, conversion coverage providing at least
the minimum benefits of a qualified plan as prescribed by section 62E.06 and the option of
a number three qualified plan, a number two qualified plan, a number one qualified plan
as provided by section 62E.06, subdivisions 1 to 3, provided application is made to the
insurer within 30 days following notice of the expiration of the continued coverage and
upon payment of the appropriate premium. The individual policy shall be renewable at the
option of the covered person as long as the covered person is not covered under another
qualified plan as defined in section 62E.02, subdivision 4. Any revisions in the table of
rate for the individual policy shall apply to the covered person's original age at entry and
shall apply equally to all similar policies issued by the insurer.

A policy providing reduced benefits at a reduced premium rate may be accepted by
the covered person in lieu of the optional coverage otherwise required by this subdivision.

Sec. 8.

Minnesota Statutes 2010, section 62A.25, subdivision 2, is amended to read:

Subd. 2.

Required coverage.

(a) Every policy, plan, certificate or contract to which
this section applies shall provide benefits for reconstructive surgery when such service is
incidental to or follows surgery resulting from injury, sickness or other diseases of the
involved part or when such service is performed on a covered dependent child new text begin to the
limiting age as defined in section 62Q.01, subdivision 7, new text end because of congenital disease
or anomaly which has resulted in a functional defect as determined by the attending
physician.

(b) The coverage limitations on reconstructive surgery in paragraph (a) do not apply
to reconstructive breast surgery following mastectomies. In these cases, coverage for
reconstructive surgery must be provided if the mastectomy is medically necessary as
determined by the attending physician.

(c) Reconstructive surgery benefits include all stages of reconstruction of the breast
on which the mastectomy has been performed, surgery and reconstruction of the other
breast to produce a symmetrical appearance, and prosthesis and physical complications
at all stages of a mastectomy, including lymphedemas, in a manner determined in
consultation with the attending physician and patient. Coverage may be subject to annual
deductible, co-payment, and coinsurance provisions as may be deemed appropriate and
as are consistent with those established for other benefits under the plan or coverage.
Coverage may not:

(1) deny to a patient eligibility, or continued eligibility, to enroll or to renew
coverage under the terms of the plan, solely for the purpose of avoiding the requirements
of this section; and

(2) penalize or otherwise reduce or limit the reimbursement of an attending provider,
or provide monetary or other incentives to an attending provider to induce the provider
to provide care to an individual participant or beneficiary in a manner inconsistent with
this section.

Written notice of the availability of the coverage must be delivered to the participant
upon enrollment and annually thereafter.

Sec. 9.

Minnesota Statutes 2010, section 62A.302, is amended to read:

62A.302 COVERAGE OF DEPENDENTS.

Subdivision 1.

Scope of coverage.

This section applies to:

(1) a health plan as defined in section 62A.011; new text begin and
new text end

deleted text begin (2) coverage described in section 62A.011, subdivision 3, clauses (4), (6), (7), (8),
(9), and (10); and
deleted text end

deleted text begin (3) deleted text end new text begin (2) new text end a policy, contract, or certificate issued by a community integrated service
network licensed under chapter 62N.

Subd. 2.

Required coverage.

Every health plan included in subdivision 1 that
provides dependent coverage must define "dependent" no more restrictively than the
definition provided in section 62L.02.

new text begin Subd. 3. new text end

new text begin Coverage of dependents by plans other than health plans.
new text end

new text begin Notwithstanding subdivision 2, the following definition of dependent applies to coverage
described in section 62A.011, subdivision 3, clauses (4), (6), (7), (8), (9), and (10);
and plans offered by the Minnesota Comprehensive Health Association. "Dependent"
means an eligible employee's spouse, unmarried child who is under the age of 25 years,
dependent child of any age who is disabled and who meets the eligibility criteria in section
62A.14, subdivision 2, or any other person whom state or federal law requires to be treated
as a dependent. For the purpose of this definition, a child includes a child for whom the
employee or the employee's spouse has been appointed legal guardian and an adoptive
child as provided in section 62A.27.
new text end

new text begin Subd. 4. new text end

new text begin Grandchildren. new text end

new text begin Nothing in this section shall be construed to require a
health carrier to make coverage available for a grandchild unless the grandchild meets the
requirements of section 62A.042. Coverage for grandchildren enrolled pursuant to section
62A.042 terminates when the first of the following occurs:
new text end

new text begin (1) the grandchild does not continue to reside with the covered grandparent;
new text end

new text begin (2) the grandparent does not provide the majority of the grandchild's support; or
new text end

new text begin (3) the grandchild reaches age 25, except as provided in section 62A.14.
new text end

Sec. 10.

Minnesota Statutes 2010, section 62A.615, is amended to read:

62A.615 PREEXISTING CONDITIONS DISCLOSED AT TIME OF
APPLICATION.

No insurer may cancel or rescind a health insurance policy for a preexisting
condition of which the application or other information provided by the insured reasonably
gave the insurer notice. No insurer may restrict coverage for a preexisting condition of
which the application or other information provided by the insured reasonably gave the
insurer notice unless the coverage is restricted at the time the policy is issued and the
restriction is disclosed in writing to the insured at the time the policy is issued.

new text begin In addition, no health plan may restrict coverage for a preexisting condition for an
individual who is under 19 years of age. This paragraph does not apply to individual
coverage that is grandfathered plan coverage, as defined in section 62Q.01, subdivision 9.
new text end

Sec. 11.

Minnesota Statutes 2010, section 62A.65, subdivision 5, is amended to read:

Subd. 5.

Portability and conversion of coverage.

(a) No individual health plan
may be offered, sold, issued, or with respect to children age 18 or under renewed, to a
Minnesota resident that contains a preexisting condition limitation, preexisting condition
exclusion, or exclusionary rider deleted text begin , unless the limitation or exclusion is permitted under
this subdivision and under chapter 62L, provided that, except for children age 18 or
under, underwriting restrictions may be retained on individual contracts that are issued
without evidence of insurability as a replacement for prior individual coverage that
was sold before May 17, 1993. The deleted text end new text begin . An new text end individual new text begin age 19 or older new text end may be subjected
to an 18-month preexisting condition limitation, unless the individual has maintained
continuous coverage as defined in section 62L.02. The individual must not be subjected
to an exclusionary rider. An individual who new text begin is age 19 or older and who new text end has maintained
continuous coverage may be subjected to a onetime preexisting condition limitation of
up to 12 months, with credit for time covered under qualifying coverage as defined in
section 62L.02, at the time that the individual first is covered under an individual health
plan by any health carrier. Credit must be given for all qualifying coverage with respect
to all preexisting conditions, regardless of whether the conditions were preexisting with
respect to any previous qualifying coverage. The individual must not be subjected to an
exclusionary rider. Thereafter, the individual new text begin who is age 19 or older new text end must not be subject to
any preexisting condition limitation, preexisting condition exclusion, or exclusionary rider
under an individual health plan by any health carrier, except an unexpired portion of a
limitation under prior coverage, so long as the individual maintains continuous coverage
as defined in section 62L.02. new text begin The prohibition on preexisting condition limitations for
children age 18 or under does not apply to individual coverage that is grandfathered plan
coverage, as defined in section 62Q.01, subdivision 9.
new text end

(b) A health carrier must offer an individual health plan to any individual previously
covered under a group health plan issued by that health carrier, regardless of the size of
the group, so long as the individual maintained continuous coverage as defined in section
62L.02. If the individual has available any continuation coverage provided under sections
62A.146; 62A.148; 62A.17, subdivisions 1 and 2; 62A.20; 62A.21; 62C.142; 62D.101; or
62D.105, or continuation coverage provided under federal law, the health carrier need not
offer coverage under this paragraph until the individual has exhausted the continuation
coverage. The offer must not be subject to underwriting, except as permitted under this
paragraph. A health plan issued under this paragraph must be a qualified plan as defined
in section 62E.02 and must not contain any preexisting condition limitation, preexisting
condition exclusion, or exclusionary rider, except for any unexpired limitation or
exclusion under the previous coverage. The individual health plan must cover pregnancy
on the same basis as any other covered illness under the individual health plan. The offer
of coverage by the health carrier must inform the individual that the coverage, including
what is covered and the health care providers from whom covered care may be obtained,
may not be the same as the individual's coverage under the group health plan. The offer
of coverage by the health carrier must also inform the individual that the individual, if
a Minnesota resident, may be eligible to obtain coverage from (i) other private sources
of health coverage, or (ii) the Minnesota Comprehensive Health Association, without a
preexisting condition limitation, and must provide the telephone number used by that
association for enrollment purposes. The initial premium rate for the individual health
plan must comply with subdivision 3. The premium rate upon renewal must comply with
subdivision 2. In no event shall the premium rate exceed 100 percent of the premium
charged for comparable individual coverage by the Minnesota Comprehensive Health
Association, and the premium rate must be less than that amount if necessary to otherwise
comply with this section. An individual health plan offered under this paragraph to a
person satisfies the health carrier's obligation to offer conversion coverage under section
62E.16, with respect to that person. Coverage issued under this paragraph must provide
that it cannot be canceled or nonrenewed as a result of the health carrier's subsequent
decision to leave the individual, small employer, or other group market. Section 72A.20,
subdivision 28, applies to this paragraph.

Sec. 12.

Minnesota Statutes 2010, section 62A.65, subdivision 6, is amended to read:

Subd. 6.

Guaranteed issue not required.

Nothing in this section requires a health
carrier to initially issue a health plan to a Minnesota resident new text begin who is age 19 or older on
the date the health plan becomes effective new text end , except as otherwise expressly provided in
subdivision 4 or 5.

Sec. 13.

Minnesota Statutes 2010, section 62C.14, subdivision 5, is amended to read:

Subd. 5.

Disabled dependents.

A subscriber's individual contract or any group
contract delivered or issued for delivery in this state and providing that coverage of
a dependent child of the subscriber or a dependent child of a covered group member
shall terminate upon attainment of a specified new text begin limiting new text end age new text begin as defined in section 62Q.01,
subdivision 7, new text end shall also provide in substance that attainment of that age shall not terminate
coverage while the child is (a) incapable of self-sustaining employment by reason of
developmental disability, mental illness or disorder, or physical disability, and (b) chiefly
dependent upon the subscriber or employee for support and maintenance, provided proof
of incapacity and dependency is furnished by the subscriber within 31 days of attainment
of the new text begin limiting new text end age new text begin as defined in section 62Q.01, subdivision 7 new text end , and subsequently as
required by the corporation, but not more frequently than annually after a two-year period
following attainment of the age. Any notice regarding termination of coverage due to
attainment of the limiting age must include information about this provision.

Sec. 14.

Minnesota Statutes 2010, section 62D.07, subdivision 3, is amended to read:

Subd. 3.

Required provisions.

Contracts and evidences of coverage shall contain:

(a) no provisions or statements which are unjust, unfair, inequitable, misleading,
deceptive, or which are untrue, misleading, or deceptive as defined in section 62D.12,
subdivision 1;

(b) a clear, concise and complete statement of:

(1) the health care services and the insurance or other benefits, if any, to which the
enrollee is entitled under the health maintenance contract;

(2) any exclusions or limitations on the services, kind of services, benefits, or kind of
benefits, to be provided, including any deductible or co-payment feature and requirements
for referrals, prior authorizations, and second opinions;

(3) where and in what manner information is available as to how services, including
emergency and out of area services, may be obtained;

(4) the total amount of payment and co-payment, if any, for health care services
and the indemnity or service benefits, if any, which the enrollee is obligated to pay
with respect to individual contracts, or an indication whether the plan is contributory or
noncontributory with respect to group certificates; and

(5) a description of the health maintenance organization's method for resolving
enrollee complaints and a statement identifying the commissioner as an external source
with whom complaints may be registered; and

(c) on the cover page of the evidence of coverage and contract, a clear and complete
statement of enrollees' rights. The statement must be in bold print and captioned
"Important Enrollee Information and Enrollee Bill of Rights" and must include but not be
limited to the following provisions in the following language or in substantially similar
language approved in advance by the commissioner, except that paragraph (8) does not
apply to prepaid health plans providing coverage for programs administered by the
commissioner of human services:

ENROLLEE INFORMATION

(1) COVERED SERVICES: Services provided by (name of health maintenance
organization) will be covered only if services are provided by participating (name of
health maintenance organization) providers or authorized by (name of health maintenance
organization). Your contract fully defines what services are covered and describes
procedures you must follow to obtain coverage.

(2) PROVIDERS: Enrolling in (name of health maintenance organization) does not
guarantee services by a particular provider on the list of providers. When a provider is
no longer part of (name of health maintenance organization), you must choose among
remaining (name of the health maintenance organization) providers.

(3) REFERRALS: Certain services are covered only upon referral. See section
(section number) of your contract for referral requirements. All referrals to non-(name of
health maintenance organization) providers and certain types of health care providers must
be authorized by (name of health maintenance organization).

(4) EMERGENCY SERVICES: Emergency services from providers who are not
affiliated with (name of health maintenance organization) will be covered deleted text begin only if proper
procedures are followed deleted text end . Your contract explains the procedures and benefits associated
with emergency care from (name of health maintenance organization) and non-(name of
health maintenance organization) providers.

(5) EXCLUSIONS: Certain services or medical supplies are not covered. You
should read the contract for a detailed explanation of all exclusions.

(6) CONTINUATION: You may convert to an individual health maintenance
organization contract or continue coverage under certain circumstances. These
continuation and conversion rights are explained fully in your contract.

(7) CANCELLATION: Your coverage may be canceled by you or (name of health
maintenance organization) only under certain conditions. Your contract describes all
reasons for cancellation of coverage.

(8) NEWBORN COVERAGE: If your health plan provides for dependent coverage,
a newborn infant is covered from birth, but only if services are provided by participating
(name of health maintenance organization) providers or authorized by (name of health
maintenance organization). Certain services are covered only upon referral. (Name
of health maintenance organization) will not automatically know of the infant's birth
or that you would like coverage under your plan. You should notify (name of health
maintenance organization) of the infant's birth and that you would like coverage. If your
contract requires an additional premium for each dependent, (name of health maintenance
organization) is entitled to all premiums due from the time of the infant's birth until the
time you notify (name of health maintenance organization) of the birth. (Name of health
maintenance organization) may withhold payment of any health benefits for the newborn
infant until any premiums you owe are paid.

(9) PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT: Enrolling in (name
of health maintenance organization) does not guarantee that any particular prescription
drug will be available nor that any particular piece of medical equipment will be available,
even if the drug or equipment is available at the start of the contract year.

ENROLLEE BILL OF RIGHTS

(1) Enrollees have the right to available and accessible services including emergency
services, as defined in your contract, 24 hours a day and seven days a week;

(2) Enrollees have the right to be informed of health problems, and to receive
information regarding treatment alternatives and risks which is sufficient to assure
informed choice;

(3) Enrollees have the right to refuse treatment, and the right to privacy of medical
and financial records maintained by the health maintenance organization and its health
care providers, in accordance with existing law;

(4) Enrollees have the right to file a complaint with the health maintenance
organization and the commissioner of health and the right to initiate a legal proceeding
when experiencing a problem with the health maintenance organization or its health
care providers;

(5) Enrollees have the right to a grace period of 31 days for the payment of each
premium for an individual health maintenance contract falling due after the first premium
during which period the contract shall continue in force;

(6) Medicare enrollees have the right to voluntarily disenroll from the health
maintenance organization and the right not to be requested or encouraged to disenroll
except in circumstances specified in federal law; and

(7) Medicare enrollees have the right to a clear description of nursing home and
home care benefits covered by the health maintenance organization.

Sec. 15.

Minnesota Statutes 2010, section 62D.105, is amended to read:

62D.105 COVERAGE OF CURRENT SPOUSE AND CHILDREN.

Subdivision 1.

Requirement.

Every health maintenance contract, which in addition
to covering the enrollee also provides coverage to the spouse and dependent children new text begin to the
limiting age as defined in section 62Q.01, subdivision 7, new text end of the enrollee new text begin who were covered
on the day before entry of a valid decree of dissolution new text end shall: (1) permit the spouse and
dependent children new text begin to the limiting age as defined in section 62Q.01, subdivision 7, new text end to
elect to continue coverage when the enrollee becomes enrolled for benefits under title
XVIII of the Social Security Act (Medicare); and (2) permit the dependent children to
continue coverage when they cease to be dependent children new text begin to the limiting age as defined
in section 62Q.01, subdivision 7, new text end under the generally applicable requirement of the plan.

Subd. 2.

Continuation privilege.

The coverage described in subdivision 1 may be
continued until the earlier of the following dates:

(1) the date coverage would otherwise terminate under the contract;

(2) 36 months after continuation by the spouse or dependent was elected; or

(3) the date the spouse or dependent children become covered under another group
health plan or Medicare.

If coverage is provided under a group policy, any required fees for the coverage shall
be paid by the enrollee on a monthly basis to the group contract holder for remittance
to the health maintenance organization. In no event shall the fee charged exceed 102
percent of the cost to the plan for such coverage for other similarly situated spouse and
dependent children new text begin to the limiting age as defined in section 62Q.01, subdivision 7, new text end to
whom subdivision 1 is not applicable, without regard to whether such cost is paid by the
employer or employee.

Sec. 16.

Minnesota Statutes 2010, section 62E.06, subdivision 1, is amended to read:

Subdivision 1.

Number three plan.

A plan of health coverage shall be certified as a
number three qualified plan if it otherwise meets the requirements established by chapters
62A, 62C, and 62Q, and the other laws of this state, whether or not the policy is issued in
Minnesota, and meets or exceeds the following minimum standards:

(a) The minimum benefits for a covered individual shall, subject to the other
provisions of this subdivision, be equal to at least 80 percent of the cost of covered
services in excess of an annual deductible which does not exceed $150 per person. The
coverage shall include a limitation of $3,000 per person on total annual out-of-pocket
expenses for services covered under this subdivision. The coverage shall be subject to
a maximum lifetime benefit of not less than $1,000,000.

The $3,000 limitation on total annual out-of-pocket expenses and the $1,000,000
maximum lifetime benefit shall not be subject to change or substitution by use of an
actuarially equivalent benefit.

(b) Covered expenses shall be the usual and customary charges for the following
services and articles when prescribed by a physician:

(1) hospital services;

(2) professional services for the diagnosis or treatment of injuries, illnesses, or
conditions, other than dental, which are rendered by a physician or at the physician's
direction;

(3) drugs requiring a physician's prescription;

(4) services of a nursing home for not more than 120 days in a year if the services
would qualify as reimbursable services under Medicare;

(5) services of a home health agency if the services would qualify as reimbursable
services under Medicare;

(6) use of radium or other radioactive materials;

(7) oxygen;

(8) anesthetics;

(9) prostheses other than dental but including scalp hair prostheses worn for hair
loss suffered as a result of alopecia areata;

(10) rental or purchase, as appropriate, of durable medical equipment other than
eyeglasses and hearing aids, unless coverage is required under section 62Q.675;

(11) diagnostic x-rays and laboratory tests;

(12) oral surgery for partially or completely unerupted impacted teeth, a tooth root
without the extraction of the entire tooth, or the gums and tissues of the mouth when not
performed in connection with the extraction or repair of teeth;

(13) services of a physical therapist;

(14) transportation provided by licensed ambulance service to the nearest facility
qualified to treat the condition; or a reasonable mileage rate for transportation to a kidney
dialysis center for treatment; and

(15) services of an occupational therapist.

(c) Covered expenses for the services and articles specified in this subdivision do
not include the following:

(1) any charge for care for injury or disease either (i) arising out of an injury in the
course of employment and subject to a workers' compensation or similar law, (ii) for
which benefits are payable without regard to fault under coverage statutorily required
to be contained in any motor vehicle, or other liability insurance policy or equivalent
self-insurance, or (iii) for which benefits are payable under another policy of accident and
health insurance, Medicare, or any other governmental program except as otherwise
provided by section 62A.04, subdivision 3, clause (4);

(2) any charge for treatment for cosmetic purposes other than for reconstructive
surgery when such service is incidental to or follows surgery resulting from injury,
sickness, or other diseases of the involved part or when such service is performed on a
covered dependent child new text begin to the limiting age as defined in section 62Q.01, subdivision
7, new text end because of congenital disease or anomaly which has resulted in a functional defect
as determined by the attending physician;

(3) care which is primarily for custodial or domiciliary purposes which would not
qualify as eligible services under Medicare;

(4) any charge for confinement in a private room to the extent it is in excess of
the institution's charge for its most common semiprivate room, unless a private room is
prescribed as medically necessary by a physician, provided, however, that if the institution
does not have semiprivate rooms, its most common semiprivate room charge shall be
considered to be 90 percent of its lowest private room charge;

(5) that part of any charge for services or articles rendered or prescribed by a
physician, dentist, or other health care personnel which exceeds the prevailing charge in
the locality where the service is provided; and

(6) any charge for services or articles the provision of which is not within the scope
of authorized practice of the institution or individual rendering the services or articles.

(d) The minimum benefits for a qualified plan shall include, in addition to those
benefits specified in clauses (a) and (e), benefits for well baby care, effective July 1,
1980, subject to applicable deductibles, coinsurance provisions, and maximum lifetime
benefit limitations.

(e) Effective July 1, 1979, the minimum benefits of a qualified plan shall include, in
addition to those benefits specified in clause (a), a second opinion from a physician on
all surgical procedures expected to cost a total of $500 or more in physician, laboratory,
and hospital fees, provided that the coverage need not include the repetition of any
diagnostic tests.

(f) Effective August 1, 1985, the minimum benefits of a qualified plan must include,
in addition to the benefits specified in clauses (a), (d), and (e), coverage for special dietary
treatment for phenylketonuria when recommended by a physician.

(g) Outpatient mental health coverage is subject to section 62A.152, subdivision 2.

Sec. 17.

Minnesota Statutes 2010, section 62L.02, subdivision 11, is amended to read:

Subd. 11.

Dependent.

"Dependent" means an eligible employee's spouse, deleted text begin unmarried
child who is under the age of 25 years deleted text end new text begin dependent child to the limiting age as defined in
section 62Q.01, subdivision 7 new text end , dependent child of any age who is disabled and who meets
the eligibility criteria in section 62A.14, subdivision 2, or any other person whom state
or federal law requires to be treated as a dependent for purposes of health plans. For the
purpose of this definition, a new text begin dependent new text end child new text begin to the limiting age as defined in section
62Q.01, subdivision 7, new text end includes a child for whom the employee or the employee's spouse
has been appointed legal guardian and an adoptive child as provided in section 62A.27.

Sec. 18.

Minnesota Statutes 2010, section 62L.02, subdivision 14a, is amended to read:

Subd. 14a.

Guaranteed issue.

"Guaranteed issue" means that a health carrier shall
not decline an application by a small employer for any health benefit plan offered by
that health carrier and shall not decline to cover under a health benefit plan any eligible
employee or eligible dependent, including persons who become eligible employees or
eligible dependents after initial issuance of the health benefit plan, subject to the health
carrier's right to impose preexisting condition limitations permitted under this chapter new text begin and
the federal act as defined in section 62Q.01, subdivision 8 new text end .

Sec. 19.

Minnesota Statutes 2010, section 62L.02, subdivision 19, is amended to read:

Subd. 19.

Late entrant.

"Late entrant" means an eligible employee or dependent
who requests enrollment in a health benefit plan of a small employer following the initial
enrollment period applicable to the employee or dependent under the terms of the health
benefit plan, provided that the initial enrollment period must be a period of at least 30
days. However, an eligible employee or dependent must not be considered a late entrant if:

(1) the individual was covered under qualifying coverage at the time the individual
was eligible to enroll in the health benefit plan, declined enrollment on that basis, and
presents to the health carrier a certificate of termination of the qualifying coverage, due to
loss of eligibility for that coverage, or proof of the termination of employer contributions
toward that coverage, provided that the individual maintains continuous coverage and
requests enrollment within 30 days of termination of qualifying coverage or termination
of the employer's contribution toward that coverage. For purposes of this clause, loss
of eligibility includes loss of eligibility as a result of legal separation, divorce, death,
termination of employment, or reduction in the number of hours of employment. For
purposes of this clause, an individual is not a late entrant if the individual elects coverage
under the health benefit plan rather than accepting continuation coverage for which the
individual is eligible under state or federal law with respect to the individual's previous
qualifying coverage;

(2) the individual has lost coverage under another group health plan due to the
expiration of benefits available under the Consolidated Omnibus Budget Reconciliation
Act of 1985, Public Law 99-272, as amended, and any state continuation laws applicable
to the employer or health carrier, provided that the individual maintains continuous
coverage and requests enrollment within 30 days of the loss of coverage;

(3) the individual is a new spouse of an eligible employee, provided that enrollment
is requested within 30 days of becoming legally married;

(4) the individual is a new dependent child new text begin to the limiting age as defined in section
62Q.01, subdivision 7, new text end of an eligible employee, provided that enrollment is requested
within 30 days of becoming a dependent;

(5) the individual is employed by an employer that offers multiple health benefit
plans and the individual elects a different plan during an open enrollment period; deleted text begin or
deleted text end

(6) a court has ordered that coverage be provided for a former spouse or dependent
child under a covered employee's health benefit plan and request for enrollment is made
within 30 days after issuance of the court order deleted text begin . deleted text end new text begin ; or
new text end

new text begin (7) the individual has enrolled according to the requirements of the federal act, as
defined in section 62Q.01, subdivision 8.
new text end

Sec. 20.

Minnesota Statutes 2010, section 62L.03, subdivision 4, is amended to read:

Subd. 4.

Underwriting restrictions.

(a) Health carriers may apply underwriting
restrictions to coverage for health benefit plans for small employers, including any
preexisting condition limitations, only as expressly permitted under this chapter new text begin and the
federal act, as defined in section 62Q.01, subdivision 8 new text end . For purposes of this section,
"underwriting restrictions" means any refusal of the health carrier to issue or renew
coverage, any premium rate higher than the lowest rate charged by the health carrier for
the same coverage, any preexisting condition limitation, preexisting condition exclusion,
or any exclusionary rider.

(b) Health carriers may collect information relating to the case characteristics and
demographic composition of small employers, as well as health status and health history
information about employees, and dependents of employees, of small employers.

(c) Except as otherwise authorized for late entrants, preexisting conditions may be
excluded by a health carrier for new text begin an individual age 19 or older for new text end a period not to exceed 12
months from the enrollment date of an eligible employee or dependent, but exclusionary
riders must not be used. Late entrants new text begin who are age 19 or older new text end may be subject to a
preexisting condition limitation not to exceed 18 months from the enrollment date of the
late entrant, but must not be subject to any exclusionary rider or preexisting condition
exclusion. When calculating any length of preexisting condition limitation, a health carrier
shall credit the time period an eligible employee or dependent was previously covered
by qualifying coverage, provided that the individual maintains continuous coverage. The
credit must be given for all qualifying coverage with respect to all preexisting conditions,
regardless of whether the conditions were preexisting with respect to any previous
qualifying coverage. Section 60A.082, relating to replacement of group coverage, and the
rules adopted under that section apply to this chapter, and this chapter's requirements are
in addition to the requirements of that section and the rules adopted under it. A health
carrier shall, at the time of first issuance or renewal of a health benefit plan on or after July
1, 1993, credit against any preexisting condition limitation or exclusion permitted under
this section, the time period prior to July 1, 1993, during which an eligible employee or
dependent was covered by qualifying coverage, if the person has maintained continuous
coverage.

(d) Health carriers shall not use pregnancy as a preexisting condition under this
chapter.

Sec. 21.

Minnesota Statutes 2010, section 62L.05, subdivision 9, is amended to read:

Subd. 9.

Dependent coverage.

Other state law and rules applicable to health plan
coverage of newborn infants, dependent children deleted text begin who do not reside with the eligible
employee deleted text end new text begin to the limiting age as defined in section 62Q.01, subdivision 7 new text end , disabled deleted text begin children
and dependents deleted text end new text begin dependent children new text end , and adopted children apply to a small employer plan.
Health benefit plans that provide dependent coverage must define "dependent" no more
restrictively than the definition provided in section 62L.02.

Sec. 22.

Minnesota Statutes 2010, section 62Q.01, is amended by adding a subdivision
to read:

new text begin Subd. 7. new text end

new text begin Dependent child to the limiting age. new text end

new text begin For purposes of chapters 60A, 62A
to 62U, and 43A, the term "dependent child to the limiting age" or "dependent children to
the limiting age" means those individuals who are eligible and covered as a dependent
child under the terms of a health plan who have not yet attained 26 years of age. A health
plan shall not deny or restrict eligibility for a dependent child to the limiting age based on
financial dependency, residency, martial status, or student status. For coverage under plans
offered by the Minnesota Comprehensive Health Association, dependent to the limiting
age means dependent as defined in section 62A.302, subdivision 3. Notwithstanding the
provisions in this subdivision, a health plan may include:
new text end

new text begin (1) eligibility requirements regarding the absence of other health plan coverage as
permitted by the federal act as defined in section 62Q.01, subdivision 8, for grandfathered
plan coverage as defined in section 62Q.01, subdivision 9; or
new text end

new text begin (2) an age greater than 26 in its policy, contract, or certificate of coverage.
new text end

Sec. 23.

Minnesota Statutes 2010, section 62Q.01, is amended by adding a subdivision
to read:

new text begin Subd. 8. new text end

new text begin Federal act. new text end

new text begin "Federal act" means the federal Public Law 111-148, 124
Stat. 119, as amended by the federal Public Law 111-152, 124 Stat. 1029, to be codified as
amended in scattered sections of United States Code, titles 26 and 42, and all amendments
thereto from time to time, or implementing regulations issued thereunder.
new text end

Sec. 24.

Minnesota Statutes 2010, section 62Q.01, is amended by adding a subdivision
to read:

new text begin Subd. 9. new text end

new text begin Grandfathered plan coverage. new text end

new text begin "Grandfathered plan coverage" means a
group or individual health plan in which an individual was enrolled on March 23, 2010,
for as long as it maintains that status in accordance with the requirements of the federal
act, as defined in section 62Q.01, subdivision 8.
new text end

Sec. 25.

Minnesota Statutes 2010, section 62Q.021, is amended to read:

62Q.021 FEDERAL ACT; COMPLIANCE REQUIRED.

new text begin Subdivision 1. new text end

new text begin Compliance with 1996 federal law. new text end

Each health plan company shall
comply with the federal Health Insurance Portability and Accountability Act of 1996,
including any federal regulations adopted under that act, to the extent that it imposes a
requirement that applies in this state and that is not also required by the laws of this state.
This section does not require compliance with any provision of the federal act prior to
the effective date provided for that provision in the federal act. The commissioner shall
enforce this section.

new text begin Subd. 2. new text end

new text begin Compliance with 2010 federal law. new text end

new text begin Each health plan company shall
comply with the federal act as defined in section 62Q.01, subdivision 8, to the extent that
it imposes a requirement that applies in this state and that is not also required by the
laws of this state. This section does not require compliance with any provision of the
federal act prior to the effective date provided for that provision in the federal act. The
commissioner shall enforce this section.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 26.

Minnesota Statutes 2010, section 62Q.23, is amended to read:

62Q.23 GENERAL SERVICES.

(a) Health plan companies shall comply with all continuation and conversion of
coverage requirements applicable to health maintenance organizations under state or
federal law.

(b) Health plan companies shall comply with sections 62A.047, 62A.27, and any
other coverage required under chapter 62A of newborn infants, dependent children deleted text begin who
do not reside with a covered person deleted text end new text begin to the limiting age as defined in section 62Q.01,
subdivision 7 new text end , disabled deleted text begin children and dependents deleted text end new text begin dependent children new text end , and adopted children.
A health plan company providing dependent coverage shall comply with section 62A.302.

(c) Health plan companies shall comply with the equal access requirements of
section 62A.15.

Sec. 27.

Minnesota Statutes 2010, section 62Q.43, subdivision 2, is amended to read:

Subd. 2.

Access requirement.

Every closed-panel health plan must allow enrollees
deleted text begin who are full-time students deleted text end under the age of deleted text begin 25 deleted text end new text begin 26 new text end years to change their designated clinic or
physician at least once per month, as long as the clinic or physician is part of the health
plan company's statewide clinic or physician network. A health plan company shall not
charge enrollees who choose this option higher premiums or cost sharing than would
otherwise apply to enrollees who do not choose this option. A health plan company may
require enrollees to provide 15 days' written notice of intent to change their designated
clinic or physician.

Sec. 28.

new text begin [62Q.46] PREVENTIVE ITEMS AND SERVICES.
new text end

new text begin Subdivision 1. new text end

new text begin Coverage for preventive items and services. new text end

new text begin (a) "Preventive items
and services" means:
new text end

new text begin (1) evidence-based items or services that have in effect a rating of A or B in the
recommendations of the United States Preventive Services Task Force as of September
23, 2010, with respect to the individual involved. For purposes of this paragraph, the
United States Preventive Services Task Force recommendations regarding breast cancer
screening, mammography, and prevention issued in or around November 2009 are not
considered to be current;
new text end

new text begin (2) immunizations for routine use in children, adolescents, and adults that have in
effect a recommendation from the Advisory Committee on Immunization Practices of
the Centers for Disease Control and Prevention with respect to the individual involved.
For purposes of this paragraph, a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention, is considered
in effect after it has been adopted by the Director of the Centers for Disease Control and
Prevention, and a recommendation is considered to be for routine use if it is listed on the
Immunization Schedules of the Centers for Disease Control and Prevention;
new text end

new text begin (3) evidence-informed preventive care and screenings provided for in comprehensive
guidelines supported by the Health Resources and Services Administration for infants,
children, and adolescents; and
new text end

new text begin (4) evidence-informed preventive care and screenings provided for in comprehensive
guidelines supported by the Health Resources and Services Administration for women.
new text end

new text begin (b) A health plan must provide coverage for preventive items and services at a
participating provider without imposing cost-sharing requirements, including a deductible,
coinsurance, or co-payment. Nothing in this section prohibits a health plan company that
has a network of providers from excluding coverage or imposing cost-sharing requirements
for preventive items or services that are delivered by an out-of-network provider.
new text end

new text begin (c) A health plan is not required to provide coverage for any items or services
specified in any recommendation or guideline described in paragraph (a) after the
recommendation or guideline is no longer included as a preventive item or service as
defined in paragraph (a). Annually, a health plan company must determine whether any
additional items or services must be covered without cost-sharing requirements or whether
any items or services are no longer required to be covered.
new text end

new text begin (d) Nothing prevents a health plan company from using reasonable medical
management techniques to determine the frequency, method, treatment, or setting for a
preventive item or service to the extent not specified in the recommendation or guideline.
new text end

new text begin (e) This section does not apply to grandfathered plan coverage, as defined in section
62Q.01, subdivision 9. This section does not apply to plans offered by the Minnesota
Comprehensive Health Association.
new text end

new text begin Subd. 2. new text end

new text begin Coverage for office visits in conjunction with preventive items and
services. new text end

new text begin (a) A health plan may impose cost-sharing requirements with respect to an office
visit if preventive item or service is billed separately or is tracked as individual encounter
data separately from the office visit.
new text end

new text begin (b) A health plan must not impose cost-sharing requirements with respect to an
office visit if a preventive item or service is not billed separately or is not tracked as an
individual encounter data separately from the office visit and the primary purpose of the
office visit is the delivery of the preventive item or service.
new text end

new text begin (c) A health plan may impose cost-sharing requirements with respect to an office
visit if a preventive item or service is not billed separately or is not tracked as individual
encounter data separately from the office visit and the primary purpose of the office visit is
not the delivery of the preventive item or service.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 29.

Minnesota Statutes 2010, section 62Q.52, is amended to read:

62Q.52 DIRECT ACCESS TO OBSTETRIC AND GYNECOLOGIC
SERVICES.

(a) Health plan companies shall allow female enrollees direct access to deleted text begin obstetricians
and gynecologists deleted text end new text begin providers who specialize in obstetrics and gynecology new text end for the following
services:

(1) deleted text begin annual preventive health examinations, which shall include a gynecologic
examination, and any subsequent obstetric or gynecologic visits determined to be
medically necessary by the examining obstetrician or gynecologist, based upon the
findings of the examination deleted text end new text begin evaluation and necessary treatment for obstetric conditions or
emergencies new text end ;

(2) maternity care; and

(3) evaluation and necessary treatment for deleted text begin acute deleted text end gynecologic conditions or
emergencies new text begin , including annual preventive health examinations new text end .

(b) For purposes of this section, "direct access" means that a female enrollee may
obtain the obstetric and gynecologic services specified in paragraph (a) from deleted text begin obstetricians
and gynecologists deleted text end new text begin providers who specialize in obstetrics and gynecology new text end in the enrollee's
network without a referral from, or prior approval through, another physician, the health
plan company, or its representatives.

(c) Health plan companies shall not require higher co-payments, coinsurance,
deductibles, or other enrollee cost-sharing for direct access.

(d) This section applies only to services described in paragraph (a) that are covered
by the enrollee's coverage, but coverage of a preventive health examination for female
enrollees must not exclude coverage of a gynecologic examination.

Sec. 30.

Minnesota Statutes 2010, section 62Q.55, is amended to read:

62Q.55 EMERGENCY SERVICES.

(a) Enrollees have the right to available and accessible emergency services, 24 hours
a day and seven days a week. The health plan company shall inform its enrollees how
to obtain emergency care deleted text begin and, if prior authorization for emergency services is required,
shall make available a toll-free number, which is answered 24 hours a day, to answer
questions about emergency services and to receive reports and provide authorizations,
where appropriate, deleted text end for treatment of emergency medical conditions. Emergency services
shall be covered whether provided by participating or nonparticipating providers and
whether provided within or outside the health plan company's service area. In reviewing
a denial for coverage of emergency services, the health plan company shall take the
following factors into consideration:

(1) a reasonable layperson's belief that the circumstances required immediate medical
care that could not wait until the next working day or next available clinic appointment;

(2) the time of day and day of the week the care was provided;

(3) the presenting symptoms, including, but not limited to, severe pain, to ensure
that the decision to reimburse the emergency care is not made solely on the basis of the
actual diagnosis;

(4) the enrollee's efforts to follow the health plan company's established procedures
for obtaining emergency care; and

(5) any circumstances that precluded use of the health plan company's established
procedures for obtaining emergency care.

(b) The health plan company may require enrollees to notify the health plan
company of nonreferred emergency care as soon as possible, but not later than 48 hours,
after the emergency care is initially provided. However, emergency care which would
have been covered under the contract had notice been provided within the set time frame
must be covered.

(c) Notwithstanding paragraphs (a) and (b), a health plan company, health insurer, or
health coverage plan that is in compliance with the rules regarding accessibility of services
adopted under section 62D.20 is in compliance with this section.

Sec. 31.

new text begin [62Q.57] DESIGNATION OF PRIMARY CARE PROVIDER.
new text end

new text begin A health plan that requires or provides for the designation of a participating primary
care provider must allow a child enrolled in the health plan to designate a physician who
specializes in pediatrics as the child's primary care provider, if such provider participates
in the network of the health plan.
new text end

Sec. 32.

Minnesota Statutes 2010, section 62Q.68, subdivision 1, is amended to read:

Subdivision 1.

Application.

For purposes of sections 62Q.68 to 62Q.72, the terms
defined in this section have the meanings given them. For purposes of sections 62Q.69
and 62Q.70, the term "health plan company" does not include an insurance company
licensed under chapter 60A to offer, sell, or issue a policy of accident and sickness
insurance as defined in section 62A.01 or a nonprofit health service plan corporation
regulated under chapter 62C that only provides dental coverage or vision coverage. For
purposes of sections 62Q.69 through 62Q.73, the term "health plan company" does
not include the Comprehensive Health Association created under chapter 62E. new text begin Section
62Q.70 does not apply to individual coverage. However, a health plan company offering
individual coverage that is grandfathered plan coverage as defined in section 62Q.01,
subdivision 9, may, pursuant to section 62Q.69, subdivision 3, paragraph (c), follow the
process outlined in section 62Q.70.
new text end

Sec. 33.

Minnesota Statutes 2010, section 62Q.69, subdivision 3, is amended to read:

Subd. 3.

Notification of complaint decisions.

(a) The health plan company must
notify the complainant in writing of its decision and the reasons for it as soon as practical
but in no case later than 30 days after receipt of a written complaint. If the health plan
company cannot make a decision within 30 days due to circumstances outside the control
of the health plan company, the health plan company may take up to 14 additional days to
notify the complainant of its decision. If the health plan company takes any additional
days beyond the initial 30-day period to make its decision, it must inform the complainant,
in advance, of the extension and the reasons for the extension.

(b) new text begin For group coverage, new text end if the decision is partially or wholly adverse to the
complainant, the notification must inform the complainant of the right to appeal the
decision to the health plan company's internal appeal process described in section 62Q.70
and the procedure for initiating an appeal.

new text begin (c) For individual coverage, if the decision is partially or wholly adverse to the
complainant, the notification must inform the complainant of the right to submit the
complaint decision to the external review process described in section 62Q.73 and the
procedure for initiating the external process. Notwithstanding the provisions in this
subdivision, a health plan company offering individual coverage that is grandfathered plan
coverage as defined in section 62Q.01, subdivision 9, may instead follow the process for
group coverage outlined in paragraph (b).
new text end

deleted text begin (c) deleted text end new text begin (d) new text end The notification must also inform the complainant of the right to submit the
complaint at any time to either the commissioner of health or commerce for investigation
and the toll-free telephone number of the appropriate commissioner.

Sec. 34.

Minnesota Statutes 2010, section 62Q.70, subdivision 1, is amended to read:

Subdivision 1.

Establishment.

(a) Each health plan company shall establish an
internal appeal process for reviewing a health plan company's decision regarding a
complaint filed in accordance with section 62Q.69. The appeal process must meet the
requirements of this section. new text begin This section applies only to group coverage. However, a
health plan company offering individual coverage that is grandfathered plan coverage as
defined in section 62Q.01, subdivision 9, may, pursuant to section 62Q.69, subdivision 3,
paragraph (c), follow the process outlined in this section.
new text end

(b) The person or persons with authority to resolve or recommend the resolution of
the internal appeal must not be solely the same person or persons who made the complaint
decision under section 62Q.69.

(c) The internal appeal process must permit the receipt of testimony, correspondence,
explanations, or other information from the complainant, staff persons, administrators,
providers, or other persons as deemed necessary by the person or persons investigating or
presiding over the appeal.

Sec. 35.

Minnesota Statutes 2010, section 62Q.71, is amended to read:

62Q.71 NOTICE TO ENROLLEES.

Each health plan company shall provide to enrollees a clear and concise description
of its complaint resolution procedure, if applicable under section 62Q.68, subdivision 1,
and the procedure used for utilization review as defined under chapter 62M as part of
the member handbook, subscriber contract, or certificate of coverage. If the health plan
company does not issue a member handbook, the health plan company may provide
the description in another written document. The description must specifically inform
enrollees:

(1) how to submit a complaint to the health plan company;

(2) if the health plan includes utilization review requirements, how to notify the
utilization review organization in a timely manner and how to obtain certification for
health care services;

(3) how to request an appeal either through the procedures described in deleted text begin sections
62Q.69 and deleted text end new text begin section new text end 62Q.70 new text begin , if applicable, new text end or through the procedures described in chapter
62M;

(4) of the right to file a complaint with either the commissioner of health or
commerce at any time during the complaint and appeal process;

(5) of the toll-free telephone number of the appropriate commissioner; and

(6) of the right new text begin , for individual and group coverage, new text end to obtain an external review
under section 62Q.73 and a description of when and how that right may be exercised deleted text begin . deleted text end new text begin ,
including that under most circumstances an enrollee must exhaust the internal complaint
or appeal process prior to external review. However, an enrollee may proceed to external
review without exhausting the internal complaint or appeal process under the following
circumstances:
new text end

new text begin (i) the health plan company waives the exhaustion requirement;
new text end

new text begin (ii) the health plan company is considered to have waived the exhaustion requirement
by failing to substantially comply with any requirements including, but not limited to,
time limits for internal complaints or appeals; or
new text end

new text begin (iii) the enrollee has applied for an expedited external review at the same time the
enrollee qualifies for and has applied for an expedited internal review under chapter 62M.
new text end

Sec. 36.

Minnesota Statutes 2010, section 62Q.73, is amended to read:

62Q.73 EXTERNAL REVIEW OF ADVERSE DETERMINATIONS.

Subdivision 1.

Definition.

For purposes of this section, "adverse determination"
means:

new text begin (1) for individual coverage, a complaint decision relating to a health care service or
claim that is partially or wholly adverse to the complainant;
new text end

new text begin (2) individual coverage offered by a health plan that is grandfathered plan coverage
as defined in section 62Q.01, subdivision 9, may instead apply the definition of "adverse
determination" for group coverage in clause (3);
new text end

deleted text begin (1) deleted text end new text begin (3) for group coverage, new text end a complaint decision relating to a health care service or
claim that has been appealed in accordance with section 62Q.70 and the appeal decision is
partially or wholly adverse to the complainant;

deleted text begin (2) deleted text end new text begin (4) new text end any initial determination not to certify that has been appealed in accordance
with section 62M.06 and the appeal did not reverse the initial determination not to certify;
deleted text begin or deleted text end

deleted text begin (3) deleted text end new text begin (5) new text end a decision relating to a health care service made by a health plan company
licensed under chapter 60A that denies the service on the basis that the service was not
medically necessary deleted text begin . deleted text end new text begin ; or
new text end

new text begin (6) the enrollee has met the requirements of subdivision 6, paragraph (e).
new text end

An adverse determination does not include complaints relating to fraudulent marketing
practices or agent misrepresentation.

Subd. 2.

Exception.

(a) This section does not apply to governmental programs
except as permitted under paragraph (b). For purposes of this subdivision, "governmental
programs" means the prepaid medical assistance program, the MinnesotaCare program,
the prepaid general assistance medical care program, the demonstration project for people
with disabilities, and the federal Medicare program.

(b) In the course of a recipient's appeal of a medical determination to the
commissioner of human services under section 256.045, the recipient may request an
expert medical opinion be arranged by the external review entity under contract to provide
independent external reviews under this section. If such a request is made, the cost of
the review shall be paid by the commissioner of human services. Any medical opinion
obtained under this paragraph shall only be used by a state human services referee as
evidence in the recipient's appeal to the commissioner of human services under section
256.045.

(c) Nothing in this subdivision shall be construed to limit or restrict the appeal rights
provided in section 256.045 for governmental program recipients.

Subd. 3.

Right to external review.

(a) Any enrollee or anyone acting on behalf
of an enrollee who has received an adverse determination may submit a written request
for an external review of the adverse determination, if applicable under section 62Q.68,
subdivision 1, or 62M.06, to the commissioner of health if the request involves a health
plan company regulated by that commissioner or to the commissioner of commerce if the
request involves a health plan company regulated by that commissioner. Notification of
the enrollee's right to external review must accompany the denial issued by the insurer.
The written request must be accompanied by a filing fee of $25. The fee may be waived
by the commissioner of health or commerce in cases of financial hardship new text begin and must be
refunded if the adverse determination is completely reversed. No enrollee may be subject
to filing fees totaling more than $75 during a plan year for group coverage or policy year
for individual coverage new text end .

(b) Nothing in this section requires the commissioner of health or commerce to
independently investigate an adverse determination referred for independent external
review.

(c) If an enrollee requests an external review, the health plan company must
participate in the external review. The cost of the external review in excess of the filing
fee described in paragraph (a) shall be borne by the health plan company.

new text begin (d) The enrollee must request external review within six months from the date of
the adverse determination.
new text end

Subd. 4.

Contract.

Pursuant to a request for proposal, the commissioner of
administration, in consultation with the commissioners of health and commerce, shall
contract with deleted text begin an organization deleted text end new text begin at least three organizations new text end or business deleted text begin entity deleted text end new text begin entities new text end to
provide independent external reviews of all adverse determinations submitted for external
review. The contract shall ensure that the fees for services rendered in connection with the
reviews deleted text begin be deleted text end new text begin are new text end reasonable.

Subd. 5.

Criteria.

deleted text begin (a) deleted text end The request for proposal must require that the entity
demonstrate:

(1) no conflicts of interest in that it is not owned, a subsidiary of, or affiliated
with a health plan company deleted text begin or deleted text end new text begin , new text end utilization review organization new text begin , or a trade organization
of health care providers new text end ;

(2) an expertise in dispute resolution;

(3) an expertise in health-related law;

(4) an ability to conduct reviews using a variety of alternative dispute resolution
procedures depending upon the nature of the dispute;

(5) an ability to new text begin maintain written records, for at least three years, regarding reviews
conducted and new text end provide data to the commissioners of health and commerce new text begin upon request new text end on
reviews conducted; deleted text begin and
deleted text end

(6) an ability to ensure confidentiality of medical records and other enrollee
information deleted text begin . deleted text end new text begin ;
new text end

new text begin (7) accreditation by a nationally recognized private accrediting organization; and
new text end

new text begin (8) the ability to provide an expedited external review process.
new text end

deleted text begin (b) The commissioner of administration shall take into consideration, in awarding
the contract according to subdivision 4, any national accreditation standards that pertain to
an external review entity.
deleted text end

Subd. 6.

Process.

(a) Upon receiving a request for an external review, the
new text begin commissioner shall assign an external review entity on a random basis. The assigned
new text end external review entity must provide immediate notice of the review to the enrollee and to
the health plan company. Within ten business days of receiving notice of the review, the
health plan company and the enrollee must provide the new text begin assigned new text end external review entity
with any information that they wish to be considered. Each party shall be provided an
opportunity to present its version of the facts and arguments. new text begin The assigned external review
entity must furnish to the health plan company any additional information submitted by
the enrollee within one business day of receipt. new text end An enrollee may be assisted or represented
by a person of the enrollee's choice.

(b) As part of the external review process, any aspect of an external review involving
a medical determination must be performed by a health care professional with expertise in
the medical issue being reviewed.

(c) An external review shall be made as soon as practical but in no case later than 40
days after receiving the request for an external review and must promptly send written
notice of the decision and the reasons for it to the enrollee, the health plan company, and
the commissioner who is responsible for regulating the health plan company.

new text begin (d) The external review entity and the clinical reviewer assigned must not have a
material professional, familial, or financial conflict of interest with:
new text end

new text begin (1) the health plan company that is the subject of the external review;
new text end

new text begin (2) the enrollee, or any parties related to the enrollee, whose treatment is the subject
of the external review;
new text end

new text begin (3) any officer, director, or management employee of the health plan company;
new text end

new text begin (4) a plan administrator, plan fiduciaries, or plan employees;
new text end

new text begin (5) the health care provider, the health care provider's group, or practice association
recommending treatment that is the subject of the external review;
new text end

new text begin (6) the facility at which the recommended treatment would be provided; or
new text end

new text begin (7) the developer or manufacturer of the principal drug, device, procedure, or other
therapy being recommended.
new text end

new text begin (e)(1) An expedited external review must be provided if the enrollee requests it
after receiving:
new text end

new text begin (i) an adverse determination that involves a medical condition for which the time
frame for completion of an expedited internal appeal would seriously jeopardize the life
or health of the enrollee or would jeopardize the enrollee's ability to regain maximum
function and the enrollee has simultaneously requested an expedited internal appeal;
new text end

new text begin (ii) an adverse determination that concerns an admission, availability of care,
continued stay, or health care service for which the enrollee received emergency services
but has not been discharged from a facility; or
new text end

new text begin (iii) an adverse determination that involves a medical condition for which the
standard external review time would seriously jeopardize the life or health of the enrollee
or jeopardize the enrollee's ability to regain maximum function.
new text end

new text begin (2) The external review entity must make its expedited determination to uphold or
reverse the adverse determination as expeditiously as possible but within no more than 72
hours after the receipt of the request for expedited review and notify the enrollee and the
health plan company of the determination.
new text end

new text begin (3) If the external review entity's notification is not in writing, the external review
entity must provide written confirmation of the determination within 48 hours of the
notification.
new text end

Subd. 7.

Standards of review.

(a) For an external review of any issue in an adverse
determination that does not require a medical necessity determination, the external review
must be based on whether the adverse determination was in compliance with the enrollee's
health benefit plan.

(b) For an external review of any issue in an adverse determination by a health plan
company licensed under chapter 62D that requires a medical necessity determination, the
external review must determine whether the adverse determination was consistent with the
definition of medically necessary care in Minnesota Rules, part 4685.0100, subpart 9b.

(c) For an external review of any issue in an adverse determination by a health plan
company, other than a health plan company licensed under chapter 62D, that requires a
medical necessity determination, the external review must determine whether the adverse
determination was consistent with the definition of medically necessary care in section
62Q.53, subdivision 2.

new text begin (d) For an external review of an adverse determination involving experimental
or investigational treatment, the external review entity must base its decision on all
documents submitted by the health plan company and enrollee, including medical
records the attending physician or health care professional's recommendation, consulting
reports from health care professionals, the terms of coverage, federal Food and Drug
Administration approval, and medical or scientific evidence or evidence-based standards.
new text end

Subd. 8.

Effects of external review.

A decision rendered under this section shall
be nonbinding on the enrollee and binding on the health plan company. The health plan
company may seek judicial review of the decision on the grounds that the decision was
arbitrary and capricious or involved an abuse of discretion.

Subd. 9.

Immunity from civil liability.

A person who participates in an external
review by investigating, reviewing materials, providing technical expertise, or rendering a
decision shall not be civilly liable for any action that is taken in good faith, that is within
the scope of the person's duties, and that does not constitute willful or reckless misconduct.

Subd. 10.

Data reporting.

The commissioners shall make available to the public,
upon request, summary data on the decisions rendered under this section, including the
number of reviews heard and decided and the final outcomes. Any data released to the
public must not individually identify the enrollee initiating the request for external review.

Sec. 37.

Minnesota Statutes 2010, section 62Q.80, subdivision 2, is amended to read:

Subd. 2.

Definitions.

For purposes of this section, the following definitions apply:

(a) "Community-based" means located in or primarily relating to the community,
as determined by the board of a community-based health initiative that is served by the
community-based health care coverage program.

(b) "Community-based health care coverage program" or "program" means a
program administered by a community-based health initiative that provides health care
services through provider members of a community-based health network or combination
of networks to eligible individuals and their dependents who are enrolled in the program.

(c) "Community-based health initiative" or "initiative" means a nonprofit corporation
that is governed by a board that has at least 80 percent of its members residing in the
community and includes representatives of the participating network providers and
employers, or a county-based purchasing organization as defined in section 256B.692.

(d) "Community-based health network" means a contract-based network of health
care providers organized by the community-based health initiative to provide or support
the delivery of health care services to enrollees of the community-based health care
coverage program on a risk-sharing or nonrisk-sharing basis.

(e) "Dependent" means an eligible employee's spouse or deleted text begin unmarried deleted text end child who
is under the age of deleted text begin 19 deleted text end new text begin 26 new text end years.

Sec. 38.

new text begin [72A.328] RESCISSION.
new text end

new text begin Subdivision 1. new text end

new text begin Prohibition on retroactively terminating coverage. new text end

new text begin (a) A health
carrier, as defined in section 62A.011, may not retroactively terminate coverage under
a health plan with respect to an individual, including a group to which the individual
belongs or family coverage in which the individual is included, after the individual is
covered under the health plan, unless:
new text end

new text begin (1) the individual or a person seeking coverage on behalf of the individual, performs
an act, practice, or omission that constitutes fraud;
new text end

new text begin (2) the individual makes an intentional misrepresentation or omission of material
fact, as prohibited by the terms of the health plan;
new text end

new text begin (3) the individual has failed to timely pay required premiums or contributions
toward the cost of coverage; or
new text end

new text begin (4) the individual has coverage under an employer health plan, and the employee
pays no premiums for coverage after termination of eligibility, and the cancellation
or discontinuance of coverage is effective retroactively to the date of termination of
eligibility due to a delay in administrative record keeping.
new text end

new text begin (b) Retroactive termination is otherwise permitted by law.
new text end

new text begin (c) This section does not apply to any benefits classified as excepted benefits under
United States Code, title 42, section 300gg-91(c), or regulations enacted there under
from time to time.
new text end

new text begin Subd. 2. new text end

new text begin Notice required. new text end

new text begin A health carrier shall provide at least 30 days advance
written notice to each individual who would be affected by the proposed rescission of
coverage before coverage under the plan may be terminated retroactively.
new text end

Sec. 39.

Minnesota Statutes 2010, section 471.61, subdivision 1a, is amended to read:

Subd. 1a.

Dependents.

Notwithstanding the provisions of Minnesota Statutes 1969,
section 471.61, as amended by Laws 1971, chapter 451, section 1, the word "dependents"
as used therein shall mean spouse and deleted text begin minor unmarried deleted text end children under the age of deleted text begin 18 deleted text end new text begin 26 new text end
years deleted text begin and dependent students under the age of 25 years actually dependent upon the
employee deleted text end .

Sec. 40. new text begin REPEALER.
new text end

new text begin Minnesota Statutes 2010, section 62E.02, subdivision 7, new text end new text begin is repealed effective the
day following final enactment.
new text end

Sec. 41. new text begin SUNSET.
new text end

new text begin If any provisions of the federal act relating to any provisions of this act are repealed,
rendered invalid by final judicial decree, or in the event the state is granted a federal
waiver from implementing provisions of the federal act, then the related provisions in
this act must sunset unless legislation is signed into law that specifically extends the
related provisions of this act. The commissioner of commerce must act within 30 days
of the repeal, invalidation, or waiver to ensure uniform implementation of this sunset
provision, taking into account the timing of health plan contract changes that may need
to be made as groups or policies renew. This action may take the form of a bulletin or
a notice in the Minnesota State Register.
new text end