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SF 3204

3rd Engrossment - 91st Legislature (2019 - 2020) Posted on 05/28/2020 04:00pm

KEY: stricken = removed, old language.
underscored = added, new language.

Current Version - 3rd Engrossment

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A bill for an act
relating to health care coverage; modifying requirements governing utilization
review and prior authorization of health care services; making conforming changes;
requiring a report; amending Minnesota Statutes 2018, sections 62M.01,
subdivisions 2, 3; 62M.02, subdivisions 2, 5, 8, 20, 21, by adding subdivisions;
62M.04, subdivisions 1, 2, 3, 4; 62M.05, subdivisions 3, 3a, 3b, 4, 5; 62M.06,
subdivisions 1, 2, 3, 4; 62M.07; 62M.09, subdivisions 3, 3a, 4, 4a, 5; 62M.10,
subdivision 7, by adding a subdivision; 62M.11; 62M.12; 62Q.71; 62Q.73,
subdivision 1; 256B.692, subdivision 2; proposing coding for new law in Minnesota
Statutes, chapter 62M; repealing Minnesota Statutes 2018, section 62M.02,
subdivision 19; Minnesota Rules, part 4685.0100, subpart 9b.

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

ARTICLE 1

UTILIZATION REVIEW AND PRIOR AUTHORIZATION OF HEALTH CARE
SERVICES

Section 1.

Minnesota Statutes 2018, section 62M.01, subdivision 2, is amended to read:


Subd. 2.

Jurisdiction.

deleted text beginSections 62M.01 to 62M.16 applydeleted text endnew text begin This chapter appliesnew text end to any
insurance company licensed under chapter 60A to offer, sell, or issue a policy of accident
and sickness insurance as defined in section 62A.01; a health service plan licensed under
chapter 62C; a health maintenance organization licensed under chapter 62D; the Minnesota
Comprehensive Health Association created under chapter 62E; a community integrated
service network licensed under chapter 62N; an accountable provider network operating
under chapter 62T; a fraternal benefit society operating under chapter 64B; a joint
self-insurance employee health plan operating under chapter 62H; a multiple employer
welfare arrangement, as defined in section 3 of the Employee Retirement Income Security
Act of 1974 (ERISA), United States Code, title 29, section 1103, as amended; a third-party
administrator licensed under section 60A.23, subdivision 8, that provides utilization review
services for the administration of benefits under a health benefit plan as defined in section
62M.02; new text beginany other entity that provides, offers, or administers hospital, outpatient, medical,
prescription drug, or other health benefits to individuals treated by a health professional
under a policy, plan, or contract;
new text endor any entity performing utilization review on behalf of a
business entity in this state pursuant to a health benefit plan covering a Minnesota resident.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 2.

Minnesota Statutes 2018, section 62M.01, subdivision 3, is amended to read:


Subd. 3.

Scope.

new text begin(a) new text endNothing in sections 62M.01 to 62M.16 applies to review of claims
after submission to determine eligibility for benefits under a health benefit plan. The appeal
procedure described in section 62M.06 applies to any complaint as defined under section
62Q.68, subdivision 2, that requires a medical determination in its resolution.

new text begin (b) This chapter does not apply to managed care plans or county-based purchasing plans
when the plan is providing coverage to state public health care program enrollees under
chapter 256B or 256L.
new text end

Sec. 3.

Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to
read:


new text begin Subd. 1a. new text end

new text begin Adverse determination. new text end

new text begin "Adverse determination" means a decision by a
utilization review organization relating to an admission, extension of stay, or health care
service that is partially or wholly adverse to the enrollee, including a decision to deny an
admission, extension of stay, or health care service on the basis that it is not medically
necessary.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 4.

Minnesota Statutes 2018, section 62M.02, subdivision 5, is amended to read:


Subd. 5.

deleted text beginCertificationdeleted text endnew text begin Authorizationnew text end.

deleted text begin"Certification"deleted text endnew text begin "Authorization"new text end means a
determination by a utilization review organization that an admission, extension of stay, or
other health care service has been reviewed and that deleted text beginitdeleted text end, based on the information provided,
deleted text begin meetsdeleted text endnew text begin it satisfiesnew text end the utilization review requirements of the applicable health plan and the
health plan company will then pay for the covered benefit, provided the preexisting limitation
provisions, the general exclusion provisions, and any deductible, co-payment, coinsurance,
or other policy requirements have been met.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 5.

Minnesota Statutes 2018, section 62M.02, subdivision 8, is amended to read:


Subd. 8.

Clinical criteria.

"Clinical criteria" means the written policies, deleted text begindecisiondeleted text end rules,
new text begin clinical protocols, new text endmedical protocols, or deleted text beginguidelinesdeleted text endnew text begin any other criteria or rationalenew text end used by
the utilization review organization to determine deleted text begincertificationdeleted text endnew text begin whether a health care service
is authorized
new text end.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 6.

Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to
read:


new text begin Subd. 10a. new text end

new text begin Emergency services. new text end

new text begin "Emergency services" has the meaning given in section
62Q.55, subdivision 3.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 7.

Minnesota Statutes 2018, section 62M.02, is amended by adding a subdivision to
read:


new text begin Subd. 13a. new text end

new text begin Medically necessary care. new text end

new text begin "Medically necessary care" has the meaning
given in section 62Q.53.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 8.

Minnesota Statutes 2018, section 62M.02, subdivision 20, is amended to read:


Subd. 20.

Utilization review.

"Utilization review" means the evaluation of the necessity,
appropriateness, and efficacy of the use of health care services, procedures, and facilities,
by a person or entity other than the attending health care professional, for the purpose of
determining the medical necessity of the service or admission. Utilization review also
includesnew text begin prior authorization andnew text end review conducted after the admission of the enrollee. It
includes situations where the enrollee is unconscious or otherwise unable to provide advance
notification. Utilization review does not include a referral or participation in a referral
process by a participating provider unless the provider is acting as a utilization review
organization.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 9.

Minnesota Statutes 2018, section 62M.02, subdivision 21, is amended to read:


Subd. 21.

Utilization review organization.

"Utilization review organization" means an
entity including but not limited to 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;
a prepaid limited health service organization issued a certificate of authority and operating
under sections 62A.451 to 62A.4528; a health service plan licensed under chapter 62C; a
health maintenance organization licensed under chapter 62D; a community integrated service
network licensed under chapter 62N; an accountable provider network operating under
chapter 62T; a fraternal benefit society operating under chapter 64B; a joint self-insurance
employee health plan operating under chapter 62H; a multiple employer welfare arrangement,
as defined in section 3 of the Employee Retirement Income Security Act of 1974 (ERISA),
United States Code, title 29, section 1103, as amended; a third-party administrator licensed
under section 60A.23, subdivision 8, which conducts utilization review and deleted text begindetermines
certification of
deleted text endnew text begin authorizes or makes adverse determinations regardingnew text end an admission, extension
of stay, or other health care services for a Minnesota resident; new text beginany other entity that provides,
offers, or administers hospital, outpatient, medical, prescription drug, or other health benefits
to individuals treated by a health professional under a policy, plan, or contract;
new text endor any entity
performing utilization review that is affiliated with, under contract with, or conducting
utilization review on behalf of, a business entity in this state. Utilization review organization
does not include a clinic or health care system acting pursuant to a written delegation
agreement with an otherwise regulated utilization review organization that contracts with
the clinic or health care system. The regulated utilization review organization is accountable
for the delegated utilization review activities of the clinic or health care system.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 10.

Minnesota Statutes 2018, section 62M.05, subdivision 3a, is amended to read:


Subd. 3a.

Standard review determination.

(a) Notwithstanding subdivision 3b, deleted text beginan
initial
deleted text endnew text begin a standard reviewnew text end determination on all requests for utilization review must be
communicated to the provider and enrollee in accordance with this subdivision within deleted text begintendeleted text endnew text begin
five
new text end business days deleted text beginofdeleted text endnew text begin after receivingnew text end the request new text beginif the request is received electronically, or
within six business days if received through nonelectronic means
new text end, provided that all
information reasonably necessary to make a determination on the request has been made
available to the utilization review organization. new text beginEffective January 1, 2022, a standard review
determination on all requests for utilization review must be communicated to the provider
and enrollee in accordance with this subdivision within five business days after receiving
the request, regardless of how the request was received, provided that all information
reasonably necessary to make a determination on the request has been made available to
the utilization review organization.
new text end

(b) When deleted text beginan initialdeleted text endnew text begin anew text end determination is made to deleted text begincertifydeleted text endnew text begin authorizenew text end, notification must be
provided promptly by telephone to the provider. The utilization review organization shall
send written notification to the provider or shall maintain an audit trail of the determination
and telephone notification. For purposes of this subdivision, "audit trail" includes
documentation of the telephone notification, including the date; the name of the person
spoken to; the enrollee; the service, procedure, or admission deleted text begincertifieddeleted text endnew text begin authorizednew text end; and the
date of the service, procedure, or admission. If the utilization review organization indicates
deleted text begin certificationdeleted text endnew text begin authorizationnew text end by use of a number, the number must be called the "deleted text begincertificationdeleted text endnew text begin
authorization
new text end number." For purposes of this subdivision, notification may also be made by
facsimile to a verified number or by electronic mail to a secure electronic mailbox. These
electronic forms of notification satisfy the "audit trail" requirement of this paragraph.

(c) When an deleted text begininitialdeleted text endnew text begin adversenew text end determination is made deleted text beginnot to certifydeleted text end, notification must be
providednew text begin within the time periods specified in paragraph (a)new text end by telephone, by facsimile to a
verified number, or by electronic mail to a secure electronic mailbox deleted text beginwithin one working
day after making the determination
deleted text end to the attending health care professional and hospitalnew text begin
or physician office
new text end as applicable. Written notification must also be sent to the hospitalnew text begin or
physician office
new text end as applicable and attending health care professional if notification occurred
by telephone. For purposes of this subdivision, notification may be made by facsimile to a
verified number or by electronic mail to a secure electronic mailbox. Written notification
must be sent to the enrollee and may be sent by United States mail, facsimile to a verified
number, or by electronic mail to a secure mailbox. The written notification must include
deleted text begin the principal reason ordeleted text endnew text begin allnew text end reasons new text beginrelied on by the utilization review organization new text endfor the
determination and the process for initiating an appeal of the determination. Upon request,
the utilization review organization shall provide the provider or enrollee with the criteria
used to determine the necessity, appropriateness, and efficacy of the health care service and
identify the database, professional treatment parameter, or other basis for the criteria. Reasons
for deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text end may include, among other things, the lack of
adequate information to deleted text begincertifydeleted text endnew text begin authorizenew text end after a reasonable attempt has been made to contact
the provider or enrollee.

(d) When an deleted text begininitialdeleted text endnew text begin adversenew text end determination is made deleted text beginnot to certifydeleted text end, the written notification
must inform the enrollee and the attending health care professional of the right to submit
an appeal to the internal appeal process described in section 62M.06 and the procedure for
initiating the internal appeal. The written notice shall be provided in a culturally and
linguistically appropriate manner consistent with the provisions of the Affordable Care Act
as defined under section 62A.011, subdivision 1a.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 11.

Minnesota Statutes 2018, section 62M.05, subdivision 3b, is amended to read:


Subd. 3b.

Expedited review determination.

(a) An expedited deleted text begininitialdeleted text end determination must
be utilized if the attending health care professional believes that an expedited determination
is warranted.

(b) Notification of an expedited deleted text begininitialdeleted text end determination to deleted text begineither certify or not to certifydeleted text endnew text begin
authorize or an expedited adverse determination
new text end must be provided to the hospital, the
attending health care professional, and the enrollee as expeditiously as the enrollee's medical
condition requires, but no later than deleted text begin72deleted text endnew text begin 48new text end hours deleted text beginfromdeleted text endnew text begin and must include at least one business
day after
new text end the initial request. When an expedited deleted text begininitialdeleted text endnew text begin adversenew text end determination is made deleted text beginnot
to certify
deleted text end, the utilization review organization must also notify the enrollee and the attending
health care professional of the right to submit an appeal to the expedited internal appeal as
described in section 62M.06 and the procedure for initiating an new text beginexpedited new text endinternal deleted text beginexpediteddeleted text end
appeal.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 12.

Minnesota Statutes 2018, section 62M.05, subdivision 4, is amended to read:


Subd. 4.

Failure to provide necessary information.

A utilization review organization
must have written procedures to address the failure of a provider or enrollee to provide the
deleted text begin necessarydeleted text end information deleted text beginfor reviewdeleted text endnew text begin necessary to make a determination on the requestnew text end. If the
enrollee or provider will not release the necessary information to the utilization review
organization, the utilization review organization may deleted text begindeny certificationdeleted text endnew text begin make an adverse
determination
new text end in accordance with its own policy or the policy described in the health benefit
plan.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 13.

Minnesota Statutes 2018, section 62M.06, subdivision 1, is amended to read:


Subdivision 1.

Procedures for appeal.

(a) A utilization review organization must have
written procedures for appeals of determinations not to certify. The right to appeal must be
available to the enrollee and to the attending health care professional.

(b) The enrollee shall be allowed to review the information relied upon in the course of
the appeal, present evidence and testimony as part of the appeals process, and receive
continued coverage pending the outcome of the appeals process. This paragraph does not
apply to deleted text beginmanaged care plans or county-based purchasing plans serving state public health
care program enrollees under section 256B.69, 256B.692, or chapter 256L, or to
deleted text end grandfathered plans as defined under section 62A.011, subdivision 1c. Nothing in this
paragraph shall be construed to limit or restrict the appeal rights of state public health care
program enrollees provided under section 256.045 and Code of Federal Regulations, title
42, section 438.420(d).

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021.
new text end

Sec. 14.

Minnesota Statutes 2018, section 62M.06, subdivision 3, is amended to read:


Subd. 3.

Standard appeal.

(a) The utilization review organization must establish
procedures for appeals to be made either in writing or by telephone.

(b) A utilization review organization shall notify in writing the enrollee, attending health
care professional, and claims administrator of its determination on the appeal within deleted text begin30
days upon
deleted text endnew text begin 15 days afternew text end receipt of the notice of appeal. If the utilization review organization
cannot make a determination within deleted text begin30deleted text endnew text begin 15new text end days due to circumstances outside the control of
the utilization review organization, the utilization review organization may take up to deleted text begin14deleted text endnew text begin
four
new text end additional days to notify the enrollee, attending health care professional, and claims
administrator of its determination. If the utilization review organization takes any additional
days beyond the initial deleted text begin30-daydeleted text endnew text begin 15-daynew text end period to make its determination, it must inform the
enrollee, attending health care professional, and claims administrator, in advance, of the
extension and the reasons for the extension.

(c) The documentation required by the utilization review organization may include copies
of part or all of the medical record and a written statement from the attending health care
professional.

(d) Prior to upholding the deleted text begininitialdeleted text endnew text begin adversenew text end determination deleted text beginnot to certifydeleted text end for clinical reasons,
the utilization review organization shall conduct a review of the documentation by a physician
who did not make the deleted text begininitialdeleted text endnew text begin adversenew text end determination deleted text beginnot to certifydeleted text end.

(e) The process established by a utilization review organization may include defining a
period within which an appeal must be filed to be considered. The time period must be
communicated to the enrollee and attending health care professional when the deleted text begininitialdeleted text endnew text begin adversenew text end
determination is made.

(f) An attending health care professional or enrollee who has been unsuccessful in an
attempt to reverse deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text end shall, consistent with section
72A.285, be provided the following:

(1) a complete summary of the review findings;

(2) qualifications of the reviewers, including any license, certification, or specialty
designation; and

(3) the relationship between the enrollee's diagnosis and the review criteria used as the
basis for the decision, including the specific rationale for the reviewer's decision.

(g) In cases of appeal to reverse deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text end for clinical
reasons, the utilization review organization must ensure that a physician of the utilization
review organization's choice in the same or a similar specialty as typically manages the
medical condition, procedure, or treatment under discussion is reasonably available to review
the case.

(h) If the deleted text begininitialdeleted text endnew text begin adversenew text end determination is not reversed on appeal, the utilization review
organization must include in its notification the right to submit the appeal to the external
review process described in section 62Q.73 and the procedure for initiating new text beginan appeal under
new text end the external process.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 15.

Minnesota Statutes 2018, section 62M.07, is amended to read:


62M.07 PRIOR AUTHORIZATION OF SERVICES.

new text begin Subdivision 1. new text end

new text begin Written standards. new text end

deleted text begin(a)deleted text end Utilization review organizations conducting prior
authorization of services must have written standards that meet at a minimum the following
requirements:

(1) written procedures and criteria used to determine whether care is appropriate,
reasonable, or medically necessary;

(2) a system for providing prompt notification of its determinations to enrollees and
providers and for notifying the provider, enrollee, or enrollee's designee of appeal procedures
under clause (4);

(3) compliance with section 62M.05, subdivisions 3a and 3b, regarding time frames for
deleted text begin approving and disapprovingdeleted text endnew text begin authorizing and making adverse determinations regardingnew text end prior
authorization requests;

(4) written procedures deleted text beginfor appeals of denialsdeleted text endnew text begin to appeal adverse determinationsnew text end of prior
authorization new text beginrequests new text endwhich specify the responsibilities of the enrollee and provider, and
which meet the requirements of sections 62M.06 and 72A.285, regarding release of summary
review findings; and

(5) procedures to ensure confidentiality of patient-specific information, consistent with
applicable law.

new text begin Subd. 2. new text end

new text begin Prior authorization of emergency services prohibited. new text end

deleted text begin(b)deleted text end No utilization
review organization, health plan company, or claims administrator may conduct or require
prior authorization of emergency confinement or new text beginan new text endemergency deleted text begintreatmentdeleted text endnew text begin servicenew text end. The
enrollee or the enrollee's authorized representative may be required to notify the health plan
company, claims administrator, or utilization review organization as soon new text beginas reasonably
possible
new text endafter the beginning of the emergency confinement or emergency deleted text begintreatment as
reasonably possible
deleted text endnew text begin servicenew text end.

new text begin Subd. 3. new text end

new text begin Retrospective revocation or limitation of prior authorization. new text end

new text begin No utilization
review organization, health plan company, or claims administrator may revoke, limit,
condition, or restrict a prior authorization that has been authorized unless there is evidence
that the prior authorization was authorized based on fraud or misinformation or a previously
approved prior authorization conflicts with state or federal law. Application of a deductible,
coinsurance, or other cost-sharing requirement does not constitute a limit, condition, or
restriction under this subdivision.
new text end

new text begin Subd. 4. new text end

new text begin Submission of prior authorization requests. new text end

deleted text begin(c)deleted text end If prior authorization for a
health care service is required, the utilization review organization, health plan company, or
claim administrator must allow providers to submit requests for prior authorization of the
health care services without unreasonable delay by telephone, facsimile, or voice mail or
through an electronic mechanism 24 hours a day, seven days a week. This deleted text beginparagraphdeleted text endnew text begin
subdivision
new text end does not apply to dental service covered under MinnesotaCare or medical
assistance.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 16.

Minnesota Statutes 2018, section 62M.09, subdivision 3, is amended to read:


Subd. 3.

Physician reviewer deleted text begininvolvementdeleted text endnew text begin; adverse determinationsnew text end.

(a) A physician
must review new text beginand make the adverse determination under section 62M.05 in new text endall cases in which
the utilization review organization has concluded that deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to
certify
deleted text end for clinical reasons is appropriate.

(b) The physician conducting the review new text beginand making the adverse determination new text endmust deleted text beginbe
licensed
deleted text endnew text begin:
new text end

new text begin (1) hold a current, unrestricted license to practice medicinenew text end in this statedeleted text begin.deleted text endnew text begin; and
new text end

new text begin (2) have the same or similar medical specialty as a provider that typically treats or
manages the condition for which the health care service has been requested.
new text end

This paragraph does not apply to reviews conducted in connection with policies issued by
a health plan company that is assessed less than three percent of the total amount assessed
by the Minnesota Comprehensive Health Association.

(c) The physician should be reasonably available by telephone to discuss the determination
with the attending health care professional.

(d) new text beginNotwithstanding paragraph (a), a review of an adverse determination involving a
prescription drug must be conducted by a licensed pharmacist or physician who is competent
to evaluate the specific clinical issues presented in the review.
new text end

new text begin (e) new text endThis subdivision does not apply to outpatient mental health or substance abuse services
governed by subdivision 3a.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 17.

Minnesota Statutes 2018, section 62M.10, subdivision 7, is amended to read:


Subd. 7.

Availability of criteria.

deleted text beginUpon request,deleted text endnew text begin (a) For utilization review determinations
other than prior authorization,
new text end a utilization review organization shallnew text begin, upon request,new text end provide
to an enrollee, a provider, and the commissioner of commerce the criteria used to determine
the medical necessity, appropriateness, and efficacy of a procedure or service and identify
the database, professional treatment guideline, or other basis for the criteria.

new text begin (b) For prior authorization determinations, a utilization review organization must submit
the organization's current prior authorization requirements and restrictions, including written,
evidence-based, clinical criteria used to make an authorization or adverse determination, to
all health plan companies for which the organization performs utilization review. A health
plan company must post on its public website the prior authorization requirements and
restrictions of any utilization review organization that performs utilization review for the
health plan company. These prior authorization requirements and restrictions must be detailed
and written in language that is easily understandable to providers.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 18.

Minnesota Statutes 2018, section 62M.10, is amended by adding a subdivision
to read:


new text begin Subd. 8. new text end

new text begin Notice; new prior authorization requirements or restrictions; change to
existing requirement or restriction.
new text end

new text begin (a) Before a utilization review organization may
implement a new prior authorization requirement or restriction or amend an existing prior
authorization requirement or restriction, the utilization review organization must submit the
new or amended requirement or restriction to all health plan companies for which the
organization performs utilization review. A health plan company must post on its website
the new or amended requirement or restriction.
new text end

new text begin (b) At least 45 days before a new prior authorization requirement or restriction or an
amended existing prior authorization requirement or restriction is implemented, the utilization
review organization, health plan company, or claims administrator must provide written or
electronic notice of the new or amended requirement or restriction to all Minnesota-based,
in-network attending health care professionals who are subject to the prior authorization
requirements and restrictions.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 19.

new text begin [62M.17] CONTINUITY OF CARE; PRIOR AUTHORIZATIONS.
new text end

new text begin Subdivision 1. new text end

new text begin Compliance with prior authorization approved by previous utilization
review organization; change in health plan company.
new text end

new text begin If an enrollee obtains coverage
from a new health plan company and the health plan company for the enrollee's new health
benefit plan uses a different utilization review organization from the enrollee's previous
health benefit plan to conduct utilization review, the health plan company for the enrollee's
new health benefit plan shall comply with a prior authorization for health care services
approved by the utilization review organization used by the enrollee's previous health benefit
plan for at least the first 60 days that the enrollee is covered under the new health benefit
plan. In order to obtain coverage for this 60-day time period, the enrollee or the enrollee's
attending health care professional must submit documentation of the previous prior
authorization to the enrollee's new health plan company according to procedures in the
enrollee's new health benefit plan. During this 60-day time period, the utilization review
organization used by the enrollee's new health plan company may conduct its own utilization
review of these health care services.
new text end

new text begin Subd. 2. new text end

new text begin Effect of change in prior authorization clinical criteria. new text end

new text begin (a) If, during a plan
year, a utilization review organization changes coverage terms for a health care service or
the clinical criteria used to conduct prior authorizations for a health care service, the change
in coverage terms or change in clinical criteria shall not apply until the next plan year for
any enrollee who received prior authorization for a health care service using the coverage
terms or clinical criteria in effect before the effective date of the change.
new text end

new text begin (b) Paragraph (a) does not apply if a utilization review organization changes coverage
terms for a drug or device that has been deemed unsafe by the United States Food and Drug
Administration (FDA); that has been withdrawn by either the FDA or the product
manufacturer; or when an independent source of research, clinical guidelines, or
evidence-based standards has issued drug- or device-specific warnings or recommended
changes in drug or device usage.
new text end

new text begin (c) Paragraph (a) does not apply if a utilization review organization changes coverage
terms for a service or the clinical criteria used to conduct prior authorizations for a service
when an independent source of research, clinical guidelines, or evidence-based standards
has recommended changes in usage of the service for reasons related to patient harm.
new text end

new text begin (d) Paragraph (a) does not apply if a utilization review organization removes a brand
name drug from its formulary or places a brand name drug in a benefit category that increases
the enrollee's cost, provided the utilization review organization (1) adds to its formulary a
generic or multisource brand name drug rated as therapeutically equivalent according to
the FDA Orange Book, or a biologic drug rated as interchangeable according to the FDA
Purple Book, at a lower cost to the enrollee, and (2) provides at least a 60-day notice to
prescribers, pharmacists, and affected enrollees.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 20.

new text begin [62M.18] ANNUAL POSTING ON WEBSITE; PRIOR AUTHORIZATIONS.
new text end

new text begin (a) By April 1, 2022, and each April 1 thereafter, a health plan company must post on
the health plan company's public website the following data for the immediately preceding
calendar year for each commercial product:
new text end

new text begin (1) the number of prior authorization requests for which an authorization was issued;
new text end

new text begin (2) the number of prior authorization requests for which an adverse determination was
issued and sorted by: (i) health care service; (ii) whether the adverse determination was
appealed; and (iii) whether the adverse determination was upheld or reversed on appeal;
new text end

new text begin (3) the number of prior authorization requests that were submitted electronically and
not by facsimile or e-mail or other method pursuant to section 62J.497; and
new text end

new text begin (4) the reasons for prior authorization denial including but not limited to:
new text end

new text begin (i) patient did not meet prior authorization criteria;
new text end

new text begin (ii) incomplete information submitted by the provider to the utilization review
organization;
new text end

new text begin (iii) change in treatment program; and
new text end

new text begin (iv) the patient is no longer covered by the plan.
new text end

new text begin (b) All information posted under this section must be written in easily understandable
language.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 21. new text beginCOMPLIANCE REPORT ON DRUG PRIOR AUTHORIZATION.
new text end

new text begin By April 1, 2021, the commissioner of health shall submit to the chairs and ranking
minority members of the legislative committees with jurisdiction over health care policy
and finance a report on compliance with the requirements for providers in Minnesota Statutes,
section 62J.497, subdivision 5. The report must include the following information from
health plans offered in the commercial fully insured and self-insured health insurance
markets:
new text end

new text begin (1) the total number of drug prior authorization requests;
new text end

new text begin (2) the frequency with which drug prior authorization requests are submitted
electronically. Electronic submission does not include facsimile or e-mail requests;
new text end

new text begin (3) the turnaround times for health plans when drug prior authorizations are submitted
electronically;
new text end

new text begin (4) the turnaround times for health plans when drug prior authorizations are not submitted
electronically;
new text end

new text begin (5) the reasons electronic drug prior authorizations are denied;
new text end

new text begin (6) the reasons nonelectronic drug prior authorizations are denied;
new text end

new text begin (7) the anticipated effect on denials and turnaround times if all providers in Minnesota
were to submit drug prior authorizations electronically;
new text end

new text begin (8) the differences between the commercial fully insured and self-insured markets for
clauses (1) to (7); and
new text end

new text begin (9) the reasons providers are not able to comply with Minnesota Statutes, section 62J.497,
subdivision 5.
new text end

Sec. 22. new text beginREPEALER.
new text end

new text begin (a) new text end new text begin Minnesota Statutes 2018, section 62M.02, subdivision 19, new text end new text begin is repealed effective
January 1, 2021.
new text end

new text begin (b) new text end new text begin Minnesota Rules, part 4685.0100, subpart 9b, new text end new text begin is repealed effective January 1, 2021.
new text end

ARTICLE 2

CONFORMING CHANGES

Section 1.

Minnesota Statutes 2018, section 62M.02, subdivision 2, is amended to read:


Subd. 2.

Appeal.

"Appeal" means a formal request, either orally or in writing, to
reconsider deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text endnew text begin regardingnew text end an admission, extension of
stay, or other health care service.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 2.

Minnesota Statutes 2018, section 62M.04, subdivision 1, is amended to read:


Subdivision 1.

Responsibility for obtaining deleted text begincertificationdeleted text endnew text begin authorizationnew text end.

A health
benefit plan that includes utilization review requirements must specify the process for
notifying the utilization review organization in a timely manner and obtaining deleted text begincertificationdeleted text endnew text begin
authorization
new text end for health care services. Each health plan company must provide a clear and
concise description of this process to an enrollee as part of the policy, subscriber contract,
or certificate of coverage. In addition to the enrollee, the utilization review organization
must allow any provider or provider's designee, or responsible patient representative,
including a family member, to fulfill the obligations under the health plan.

A claims administrator that contracts directly with providers for the provision of health
care services to enrollees may, through contract, require the provider to notify the review
organization in a timely manner and obtain deleted text begincertificationdeleted text endnew text begin authorizationnew text end for health care services.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 3.

Minnesota Statutes 2018, section 62M.04, subdivision 2, is amended to read:


Subd. 2.

Information upon which utilization review is conducted.

(a) If the utilization
review organization is conducting routine prospective and concurrent utilization review,
utilization review organizations must collect only the information necessary to deleted text begincertifydeleted text endnew text begin
authorize
new text end the admission, procedure of treatment, and length of stay.

(b) Utilization review organizations may request, but may not require providers to supplynew text begin,new text end
numerically encoded diagnoses or procedures as part of the deleted text begincertificationdeleted text endnew text begin authorizationnew text end
process.

(c) Utilization review organizations must not routinely request copies of medical records
for all patients reviewed. In performing prospective and concurrent review, copies of the
pertinent portion of the medical record should be required only when a difficulty develops
in deleted text begincertifyingdeleted text endnew text begin authorizingnew text end the medical necessity or appropriateness of the admission or
extension of stay.

(d) Utilization review organizations may request copies of medical records retrospectively
for a number of purposes, including auditing the services provided, quality assurance review,
ensuring compliance with the terms of either the health benefit plan or the provider contract,
and compliance with utilization review activities. Except for reviewing medical records
associated with an appeal or with an investigation or audit of data discrepancies, providers
must be reimbursed for the reasonable costs of duplicating records requested by the utilization
review organization for retrospective review unless otherwise provided under the terms of
the provider contract.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 4.

Minnesota Statutes 2018, section 62M.04, subdivision 3, is amended to read:


Subd. 3.

Data elements.

(a) Except as otherwise provided in deleted text beginsections 62M.01 to 62M.16deleted text endnew text begin
this chapter
new text end, for purposes of deleted text begincertificationdeleted text endnew text begin authorizationnew text end a utilization review organization
must limit its data requirements to the following elements:

(b) Patient information that includes the following:

(1) name;

(2) address;

(3) date of birth;

(4) sex;

(5) Social Security number or patient identification number;

(6) name of health plan company or health plan; and

(7) plan identification number.

(c) Enrollee information that includes the following:

(1) name;

(2) address;

(3) Social Security number or employee identification number;

(4) relation to patient;

(5) employer;

(6) health benefit plan;

(7) group number or plan identification number; and

(8) availability of other coverage.

(d) Attending health care professional information that includes the following:

(1) name;

(2) address;

(3) telephone numbers;

(4) degree and license;

(5) specialty or board certification status; and

(6) tax identification number or other identification number.

(e) Diagnosis and treatment information that includes the following:

(1) primary diagnosis with associated ICD or DSM coding, if available;

(2) secondary diagnosis with associated ICD or DSM coding, if available;

(3) tertiary diagnoses with associated ICD or DSM coding, if available;

(4) proposed procedures or treatments with ICD or associated CPT codes, if available;

(5) surgical assistant requirement;

(6) anesthesia requirement;

(7) proposed admission or service dates;

(8) proposed procedure date; and

(9) proposed length of stay.

(f) Clinical information that includes the following:

(1) support and documentation of appropriateness and level of service proposed; and

(2) identification of contact person for detailed clinical information.

(g) Facility information that includes the following:

(1) type;

(2) licensure and certification status and DRG exempt status;

(3) name;

(4) address;

(5) telephone number; and

(6) tax identification number or other identification number.

(h) Concurrent or continued stay review information that includes the following:

(1) additional days, services, or procedures proposed;

(2) reasons for extension, including clinical information sufficient for support of
appropriateness and level of service proposed; and

(3) diagnosis status.

(i) For admissions to facilities other than acute medical or surgical hospitals, additional
information that includes the following:

(1) history of present illness;

(2) patient treatment plan and goals;

(3) prognosis;

(4) staff qualifications; and

(5) 24-hour availability of staff.

Additional information may be required for other specific review functions such as
discharge planning or catastrophic case management. Second opinion information may also
be required, when applicable, to support benefit plan requirements.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 5.

Minnesota Statutes 2018, section 62M.04, subdivision 4, is amended to read:


Subd. 4.

Additional information.

A utilization review organization may request
information in addition to that described in subdivision 3 when there is significant lack of
agreement between the utilization review organization and the provider regarding the
appropriateness of deleted text begincertificationdeleted text endnew text begin authorizationnew text end during the review or appeal process. For
purposes of this subdivision, "significant lack of agreement" means that the utilization
review organization has:

(1) tentatively determined through its professional staff that a service cannot be deleted text begincertifieddeleted text endnew text begin
authorized
new text end;

(2) referred the case to a physician for review; and

(3) talked to or attempted to talk to the attending health care professional for further
information.

Nothing in deleted text beginsections 62M.01 to 62M.16deleted text endnew text begin this chapternew text end prohibits a utilization review
organization from requiring submission of data necessary to comply with the quality
assurance and utilization review requirements of chapter 62D or other appropriate data or
outcome analyses.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 6.

Minnesota Statutes 2018, section 62M.05, subdivision 3, is amended to read:


Subd. 3.

Notification of new text beginadverse new text enddeterminationsnew text begin and authorizationsnew text end.

A utilization
review organization must have written procedures for providing notification of deleted text beginits
determinations on
deleted text end all deleted text begincertificationsdeleted text endnew text begin its adverse determinations and authorizationsnew text end in
accordance with this section.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 7.

Minnesota Statutes 2018, section 62M.05, subdivision 5, is amended to read:


Subd. 5.

Notification to claims administrator.

If the utilization review organization
and the claims administrator are separate entities, the utilization review organization must
forward, electronically or in writing, a notification of deleted text begincertification or determination not to
certify
deleted text endnew text begin an authorization or adverse determinationnew text end to the appropriate claims administrator
for the health benefit plan. If it is determined by the claims administrator that the deleted text begincertifieddeleted text endnew text begin
authorized
new text end health care service is not covered by the health benefit plan, the claims
administrator must promptly notify the claimant and provider of this information.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 8.

Minnesota Statutes 2018, section 62M.06, subdivision 1, is amended to read:


Subdivision 1.

Procedures for appeal.

(a) A utilization review organization must have
written procedures for appeals of new text beginadverse new text enddeterminations deleted text beginnot to certifydeleted text end. The right to appeal
must be available to the enrollee and to the attending health care professional.

(b) The enrollee shall be allowed to review the information relied upon in the course of
the appeal, present evidence and testimony as part of the appeals process, and receive
continued coverage pending the outcome of the appeals process. This paragraph does not
apply to managed care plans or county-based purchasing plans serving state public health
care program enrollees under section 256B.69, 256B.692, or chapter 256L, or to
grandfathered plans as defined under section 62A.011, subdivision 1c. Nothing in this
paragraph shall be construed to limit or restrict the appeal rights of state public health care
program enrollees provided under section 256.045 and Code of Federal Regulations, title
42, section 438.420(d).

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 9.

Minnesota Statutes 2018, section 62M.06, subdivision 2, is amended to read:


Subd. 2.

Expedited appeal.

(a) When an deleted text begininitialdeleted text endnew text begin adversenew text end determination deleted text beginnot to certifydeleted text endnew text begin fornew text end
a health care service is made prior to or during an ongoing service requiring review and the
attending health care professional believes that the determination warrants an expedited
appeal, the utilization review organization must ensure that the enrollee and the attending
health care professional have an opportunity to appeal the determination over the telephone
on an expedited basis. In such an appeal, the utilization review organization must ensure
reasonable access to its consulting physician or health care provider.

(b) The utilization review organization shall notify the enrollee and attending health
care professional by telephone of its determination on the expedited appeal as expeditiously
as the enrollee's medical condition requires, but no later than 72 hours after receiving the
expedited appeal.

(c) If the new text beginadverse new text enddetermination deleted text beginnot to certifydeleted text end is not reversed through the expedited
appeal, the utilization review organization must include in its notification the right to submit
the appeal to the external appeal process described in section 62Q.73 and the procedure for
initiating the process. This information must be provided in writing to the enrollee and the
attending health care professional as soon as practical.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 10.

Minnesota Statutes 2018, section 62M.06, subdivision 4, is amended to read:


Subd. 4.

Notification to claims administrator.

If the utilization review organization
and the claims administrator are separate entities, the utilization review organization must
notify, either electronically or in writing, the appropriate claims administrator for the health
benefit plan of anynew text begin adversenew text end determination deleted text beginnot to certifydeleted text end that is reversed on appeal.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 11.

Minnesota Statutes 2018, section 62M.09, subdivision 3a, is amended to read:


Subd. 3a.

Mental health and substance abuse reviews.

(a) A peer of the treating mental
health or substance abuse provider, a doctoral-level psychologist, or a physician must review
requests for outpatient services in which the utilization review organization has concluded
that deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text endnew text begin fornew text end a mental health or substance abuse service
for clinical reasons is appropriate, provided that any final new text beginadverse new text enddetermination deleted text beginnot to
certify
deleted text endnew text begin issued under section 62M.05 for anew text end treatment is made by a psychiatrist certified by
the American Board of Psychiatry and Neurology and appropriately licensed in this state
or by a doctoral-level psychologist licensed in this state.

(b) Notwithstanding paragraph (a), a doctoral-level psychologist shall not review any
request or final new text beginadverse new text enddetermination deleted text beginnot to certifydeleted text endnew text begin fornew text end a mental health or substance abuse
service or treatment if the treating provider is a psychiatrist.

(c) Notwithstanding the notification requirements of section 62M.05, a utilization review
organization that has made deleted text beginan initial decisiondeleted text endnew text begin an adverse determinationnew text end to deleted text begincertifydeleted text endnew text begin authorizenew text end
in accordance with the requirements of section 62M.05 may elect to provide notification of
a determination to continue coverage through facsimile or mail.

(d) This subdivision does not apply to determinations made in connection with policies
issued by a health plan company that is assessed less than three percent of the total amount
assessed by the Minnesota Comprehensive Health Association.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 12.

Minnesota Statutes 2018, section 62M.09, subdivision 4, is amended to read:


Subd. 4.

Dentist plan reviews.

A dentist must review all cases in which the utilization
review organization has concluded that deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text endnew text begin fornew text end a dental
service or procedure for clinical reasons is appropriate and an appeal has been made by the
attending dentist, enrollee, or designee.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 13.

Minnesota Statutes 2018, section 62M.09, subdivision 4a, is amended to read:


Subd. 4a.

Chiropractic review.

A chiropractor must review all cases in which the
utilization review organization has concluded that deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text endnew text begin
for
new text end a chiropractic service or procedure for clinical reasons is appropriate and an appeal has
been made by the attending chiropractor, enrollee, or designee.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 14.

Minnesota Statutes 2018, section 62M.09, subdivision 5, is amended to read:


Subd. 5.

Written clinical criteria.

A utilization review organization's decisions must
be supported by written clinical criteria and review procedures. Clinical criteria and review
procedures must be established with appropriate involvement from actively practicing
physicians. A utilization review organization must use written clinical criteria, as required,
for determining the appropriateness of the deleted text begincertificationdeleted text endnew text begin authorizationnew text end request. The utilization
review organization must have a procedure for ensuring, at a minimum, the annual evaluation
and updating of the written criteria based on sound clinical principles.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 15.

Minnesota Statutes 2018, section 62M.11, is amended to read:


62M.11 COMPLAINTS TO COMMERCE OR HEALTH.

Notwithstanding the provisions of deleted text beginsections 62M.01 to 62M.16deleted text endnew text begin this chapternew text end, an enrollee
may file a complaint regarding deleted text beginadeleted text endnew text begin an adversenew text end determination deleted text beginnot to certifydeleted text end directly to the
commissioner responsible for regulating the utilization review organization.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 16.

Minnesota Statutes 2018, section 62M.12, is amended to read:


62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES.

No individual who is performing utilization review may receive any financial incentive
based on the number of deleted text begindenials of certificationsdeleted text endnew text begin adverse determinationsnew text end made by such
individual, provided that utilization review organizations may establish medically appropriate
performance standards. This prohibition does not apply to financial incentives established
between health plan companies and providers.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 17.

Minnesota Statutes 2018, 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 deleted text begincertificationdeleted text endnew text begin authorizationnew text end for
health care services;

(3) how to request an appeal either through the procedures described in section 62Q.70,
if applicable, 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, for individual and group coverage, to obtain an external review under
section 62Q.73 and a description of when and how that right may be exercised, 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:

(i) the health plan company waives the exhaustion requirement;

(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

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

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 18.

Minnesota Statutes 2018, section 62Q.73, subdivision 1, is amended to read:


Subdivision 1.

Definition.

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

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

(2) an individual health plan that is grandfathered plan coverage may instead apply the
definition of adverse determination for group coverage in clause (3);

(3) for group health plans, 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;

(4) any deleted text begininitialdeleted text endnew text begin adversenew text end determination deleted text beginnot to certifydeleted text endnew text begin, as defined in section 62M.02,
subdivision 1a,
new text end that has been appealed in accordance with section 62M.06 and the appeal
did not reverse the deleted text begininitialdeleted text endnew text begin adversenew text end determination deleted text beginnot to certifydeleted text end;

(5) 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; or

(6) the enrollee has met the requirements of subdivision 6, paragraph (e).

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

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 19.

Minnesota Statutes 2018, section 256B.692, subdivision 2, is amended to read:


Subd. 2.

Duties of commissioner of health.

(a) Notwithstanding chapters 62D and 62N,
a county that elects to purchase medical assistance in return for a fixed sum without regard
to the frequency or extent of services furnished to any particular enrollee is not required to
obtain a certificate of authority under chapter 62D or 62N. The county board of
commissioners is the governing body of a county-based purchasing program. In a multicounty
arrangement, the governing body is a joint powers board established under section 471.59.

(b) A county that elects to purchase medical assistance services under this section must
satisfy the commissioner of health that the requirements for assurance of consumer protection,
provider protection, and fiscal solvency of chapter 62D, applicable to health maintenance
organizations will be met according to the following schedule:

(1) for a county-based purchasing plan approved on or before June 30, 2008, the plan
must have in reserve:

(i) at least 50 percent of the minimum amount required under chapter 62D as of January
1, 2010;

(ii) at least 75 percent of the minimum amount required under chapter 62D as of January
1, 2011;

(iii) at least 87.5 percent of the minimum amount required under chapter 62D as of
January 1, 2012; and

(iv) at least 100 percent of the minimum amount required under chapter 62D as of January
1, 2013; and

(2) for a county-based purchasing plan first approved after June 30, 2008, the plan must
have in reserve:

(i) at least 50 percent of the minimum amount required under chapter 62D at the time
the plan begins enrolling enrollees;

(ii) at least 75 percent of the minimum amount required under chapter 62D after the first
full calendar year;

(iii) at least 87.5 percent of the minimum amount required under chapter 62D after the
second full calendar year; and

(iv) at least 100 percent of the minimum amount required under chapter 62D after the
third full calendar year.

(c) Until a plan is required to have reserves equaling at least 100 percent of the minimum
amount required under chapter 62D, the plan may demonstrate its ability to cover any losses
by satisfying the requirements of chapter 62N. A county-based purchasing plan must also
assure the commissioner of health that the requirements of sections 62J.041; 62J.48; 62J.71
to 62J.73; deleted text begin62M.01 to 62M.16;deleted text end all applicable provisions of chapter 62Q, including sections
62Q.075; 62Q.1055; 62Q.106; 62Q.12; 62Q.135; 62Q.14; 62Q.145; 62Q.19; 62Q.23,
paragraph (c)
; 62Q.43; 62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58; 62Q.68 to 62Q.72;
and 72A.201 will be met.

(d) All enforcement and rulemaking powers available under chapters 62D, 62J, deleted text begin62M,deleted text end
62N, and 62Q are hereby granted to the commissioner of health with respect to counties
that purchase medical assistance services under this section.

(e) The commissioner, in consultation with county government, shall develop
administrative and financial reporting requirements for county-based purchasing programs
relating to sections 62D.041, 62D.042, 62D.045, 62D.08, 62N.28, 62N.29, and 62N.31,
and other sections as necessary, that are specific to county administrative, accounting, and
reporting systems and consistent with other statutory requirements of counties.

(f) The commissioner shall collect from a county-based purchasing plan under this
section the following fees:

(1) fees attributable to the costs of audits and other examinations of plan financial
operations. These fees are subject to the provisions of Minnesota Rules, part 4685.2800,
subpart 1, item F; and

(2) an annual fee of $21,500, to be paid by June 15 of each calendar year.

All fees collected under this paragraph shall be deposited in the state government special
revenue fund.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021.
new text end

Sec. 20. new text beginREVISOR INSTRUCTIONS.
new text end

new text begin (a) In Minnesota Statutes, chapter 62M, the revisor of statutes shall replace references
to "sections 62M.01 to 62M.16" with "this chapter." The revisor shall make any necessary
technical and conforming changes to sentence structure to preserve the meaning of the text.
new text end

new text begin (b) The revisor of statutes shall replace the term "DETERMINATIONS NOT TO
CERTIFY" with "ADVERSE DETERMINATIONS" in the section headnote for Minnesota
Statutes, section 62M.06.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin Paragraph (a) is effective August 1, 2020. Paragraph (b) is effective
January 1, 2021.
new text end

APPENDIX

Repealed Minnesota Statutes: S3204-3

62M.02 DEFINITIONS.

Subd. 19.

Reconsideration request.

"Reconsideration request" means an initial request by telephone for additional review of a utilization review organization's determination not to certify an admission, extension of stay, or other health care service.

Repealed Minnesota Rule: S3204-3

4685.0100 DEFINITIONS.

Subp. 9b.

Medically necessary care.

"Medically necessary care" means health care services appropriate, in terms of type, frequency, level, setting, and duration, to the enrollee's diagnosis or condition, and diagnostic testing and preventive services. Medically necessary care must:

A.

be consistent with generally accepted practice parameters as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure, or treatment at issue; and

B.

help restore or maintain the enrollee's health; or

C.

prevent deterioration of the enrollee's condition; or

D.

prevent the reasonably likely onset of a health problem or detect an incipient problem.