Office of the Revisor of Statutes
Minnesota Session Laws - 1995, Regular Session
Key: (1) language to be deleted (2) new language
CHAPTER 234-S.F.No. 845
An act relating to health; MinnesotaCare; expanding
provisions of health care; establishing requirements
for integrated service networks; modifying
requirements for health plan companies; repealing the
regulated all-payer option; modifying universal
coverage and insurance reform provisions; revising the
research and data initiatives; modifying eligibility
for the MinnesotaCare program; creating the
prescription drug purchasing authority; establishing a
drug purchasing benefit program for senior citizens;
extending the health care commission and regional
coordinating boards; making technical changes;
providing penalties; appropriating money; amending
Minnesota Statutes 1994, sections 13.99, by adding a
subdivision; 16A.724; 60A.02, by adding a subdivision;
60B.02; 60B.03, subdivision 2; 60G.01, subdivisions 2,
4, and 5; 62A.10, subdivisions 1 and 2; 62A.65,
subdivisions 5 and 8; 62D.02, subdivision 8; 62D.042,
subdivision 2; 62D.11, subdivision 1; 62D.181,
subdivisions 2, 3, 6, and 9; 62E.05; 62E.141; 62H.04;
62H.08; 62J.017; 62J.04, subdivisions 1a and 3;
62J.05, subdivisions 2 and 9; 62J.06; 62J.09,
subdivisions 1, 1a, 2, 6, 8, and by adding a
subdivision; 62J.152, subdivision 5; 62J.17,
subdivisions 4a, 6a, and by adding a subdivision;
62J.212; 62J.37; 62J.38; 62J.40; 62J.41, subdivisions
1 and 2; 62J.48; 62J.54; 62J.55; 62J.58; 62L.02,
subdivisions 11, 16, 24, and 26; 62L.03, subdivisions
3, 4, and 5; 62L.09, subdivision 1; 62L.12,
subdivision 2; 62L.17, by adding a subdivision;
62L.18, subdivision 2; 62M.07; 62M.09, subdivision 5;
62M.10, by adding a subdivision; 62N.02, by adding
subdivisions; 62N.04; 62N.10, by adding a subdivision;
62N.11, subdivision 1; 62N.13; 62N.14, subdivision 3;
62N.25, subdivision 2; 62P.05, subdivision 4, and by
adding a subdivision; 62Q.01, subdivisions 2, 3, 4,
and by adding subdivisions; 62Q.03, subdivisions 1, 6,
7, 8, 9, 10, and by adding subdivisions; 62Q.07,
subdivisions 1 and 2; 62Q.075, subdivision 4; 62Q.09,
subdivision 3; 62Q.11, subdivision 2; 62Q.165; 62Q.17,
subdivisions 2, 6, 8, and by adding a subdivision;
62Q.18; 62Q.19; 62Q.30; 62Q.32; 62Q.33, subdivisions 4
and 5; 62Q.41; 72A.20, by adding subdivisions;
72A.201, by adding a subdivision; 136A.1355,
subdivisions 3 and 5; 136A.1356, subdivisions 3 and 4;
144.1464, subdivisions 2, 3, and 4; 144.147,
subdivision 1; 144.1484, subdivision 1; 144.1486,
subdivision 4; 144.1487, subdivision 1; 144.1488,
subdivisions 1 and 4; 144.1489, subdivisions 1, 3, and
4; 144.1490; 144.1491, subdivision 2; 144.801, by
adding a subdivision; 144.804, subdivision 1; 145.414;
148B.32, subdivision 1; 151.48; 214.16, subdivisions 2
and 3; 256.9354, subdivisions 1, 4, 5, and by adding a
subdivision; 256.9355, subdivision 2; 256.9357,
subdivisions 1, 2, and 3; 256.9358, subdivisions 3, 4,
and by adding a subdivision; 256.9363, subdivision 5;
256B.037, subdivisions 1, 3, 4, and by adding
subdivisions; 256B.04, by adding a subdivision;
256B.055, by adding a subdivision; 256B.057, by adding
subdivisions; 256B.0625, subdivision 30; 256B.69,
subdivisions 2 and 4; 270.101, subdivision 1; 295.50,
subdivisions 3, 4, and 10a; 295.53, subdivisions 1, 3,
and 4; 295.55, subdivision 4; 295.57; and 295.582;
Laws 1990, chapter 591, article 4, section 9; Laws
1993, chapter 224, article 4, section 40; Laws 1993,
First Special Session chapter 1, article 8, section
30, subdivision 2; Laws 1994, chapter 625, article 5,
sections 5, subdivision 1; 7; and 10, subdivision 2;
proposing coding for new law in Minnesota Statutes,
chapters 16B; 62J; 62L; 62N; 62Q; 62R; 137; 144; 256;
256B; and 295; repealing Minnesota Statutes 1994,
sections 62J.045; 62J.07, subdivision 4; 62J.09,
subdivision 1a; 62J.152, subdivision 6; 62J.19;
62J.30; 62J.31; 62J.32; 62J.33; 62J.34; 62J.35;
62J.41, subdivisions 3 and 4; 62J.44; 62J.45; 62J.65;
62L.08, subdivision 7a; 62N.34; 62P.01; 62P.02;
62P.03; 62P.07; 62P.09; 62P.11; 62P.13; 62P.15;
62P.17; 62P.19; 62P.21; 62P.23; 62P.25; 62P.27;
62P.29; 62P.31; 62P.33; 62Q.03, subdivisions 2, 3, 4,
5, and 11; 62Q.18, subdivisions 2, 3, 4, 5, 6, 8, and
9; 62Q.21; 62Q.27; 144.1488, subdivision 2; 148.236;
and 256.9353, subdivisions 4 and 5; Laws 1993, chapter
247, article 1, sections 12, 13, 14, 15, 18, and 19;
Minnesota Rules, part 4685.1700, subpart 1, item D.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
ARTICLE 1
INTEGRATED SERVICE NETWORKS
Section 1. Minnesota Statutes 1994, section 60B.02, is
amended to read:
60B.02 [PERSONS COVERED.]
The proceedings authorized by sections 60B.01 to 60B.61 may
be applied to:
(1) All insurers who are doing, or have done, an insurance
business in this state, and against whom claims arising from
that business may exist now or in the future;
(2) All insurers who purport to do an insurance business in
this state;
(3) All insurers who have insureds resident in this state;
(4) All other persons organized or in the process of
organizing with the intent to do an insurance business in this
state; and
(5) All nonprofit service plan corporations incorporated or
operating under the nonprofit health service plan corporation
act, any health plan incorporated under chapter 317A, all
fraternal benefit societies operating under chapter 64B, except
those associations enumerated in section 64B.38, all assessment
benefit associations operating under chapter 63, all township
mutual or other companies operating under chapter 67A, and all
reciprocals or interinsurance exchanges operating under chapter
71A, and all integrated service networks operating under chapter
62N.
Sec. 2. Minnesota Statutes 1994, section 60B.03,
subdivision 2, is amended to read:
Subd. 2. [COMMISSIONER.] "Commissioner" means the
commissioner of commerce of the state of Minnesota and, in that
commissioner's absence or disability, a deputy or other person
duly designated to act in that commissioner's place. In the
context of rehabilitation or liquidation of a health maintenance
organization or integrated service network, "commissioner" means
the commissioner of health of the state of Minnesota and, in
that commissioner's absence or disability, a deputy or other
person duly designated to act in that commissioner's place.
Sec. 3. Minnesota Statutes 1994, section 60G.01,
subdivision 2, is amended to read:
Subd. 2. [COMMISSIONER.] "Commissioner" means the
commissioner of commerce, except that "commissioner" means the
commissioner of health for administrative supervision of health
maintenance organizations and integrated service networks.
Sec. 4. Minnesota Statutes 1994, section 60G.01,
subdivision 4, is amended to read:
Subd. 4. [DEPARTMENT.] "Department" means the department
of commerce, except that "department" means the department of
health for administrative supervision of health maintenance
organizations and integrated service networks.
Sec. 5. Minnesota Statutes 1994, section 60G.01,
subdivision 5, is amended to read:
Subd. 5. [INSURER.] "Insurer" means and includes every
person engaged as indemnitor, surety, or contractor in the
business of entering into contracts of insurance or of annuities
as limited to:
(1) any insurer who is doing an insurer business, or has
transacted insurance in this state, and against whom claims
arising from that transaction may exist now or in the future;
(2) any fraternal benefit society which is subject to
chapter 64B;
(3) nonprofit health service plan corporations subject to
chapter 62C;
(4) cooperative life and casualty companies subject to
sections 61A.39 to 61A.52; and
(5) health maintenance organizations regulated under
chapter 62D; and
(6) integrated service networks regulated under chapter 62N.
Sec. 6. Minnesota Statutes 1994, section 62D.181,
subdivision 2, is amended to read:
Subd. 2. [ELIGIBLE INDIVIDUALS.] An individual is eligible
for alternative coverage under this section if:
(1) the individual had individual health coverage through a
health maintenance organization, integrated service network, or
community integrated service network, the coverage is no longer
available due to the insolvency of the health maintenance
organization, integrated service network, or community
integrated service network, and the individual has not obtained
alternative coverage; or
(2) the individual had group health coverage through a
health maintenance organization, integrated service network, or
community integrated service network, the coverage is no longer
available due to the insolvency of the health maintenance
organization, integrated service network, or community
integrated service network, and the individual has not obtained
alternative coverage.
Sec. 7. Minnesota Statutes 1994, section 62D.181,
subdivision 3, is amended to read:
Subd. 3. [APPLICATION AND ISSUANCE.] If a health
maintenance organization, integrated service network, or
community integrated service network will be liquidated,
individuals eligible for alternative coverage under subdivision
2 may apply to the association to obtain alternative coverage.
Upon receiving an application and evidence that the applicant
was enrolled in the health maintenance organization, integrated
service network, or community integrated service network at the
time of an order for liquidation, the association shall issue
policies to eligible individuals, without the limitation on
preexisting conditions described in section 62E.14, subdivision
3.
Sec. 8. Minnesota Statutes 1994, section 62D.181,
subdivision 6, is amended to read:
Subd. 6. [DURATION.] The duration of alternative coverage
issued under this section is:
(1) for individuals eligible under subdivision 2, clause
(1), 90 days; and
(2) for individuals eligible under subdivision 2, clause
(2), 90 days or the length of time remaining in the group
contract with the insolvent health maintenance organization,
integrated service network, or community integrated service
network, whichever is greater.
Sec. 9. Minnesota Statutes 1994, section 62D.181,
subdivision 9, is amended to read:
Subd. 9. [COORDINATION OF POLICIES.] If an insolvent
health maintenance organization, integrated service network, or
community integrated service network has insolvency insurance
coverage at the time of an order for liquidation, the
association may coordinate the benefits of the policy issued
under this section with those of the insolvency insurance policy
available to the enrollees. The premium level for the combined
association policy and the insolvency insurance policy may not
exceed those described in subdivision 5.
Sec. 10. Minnesota Statutes 1994, section 62N.02, is
amended by adding a subdivision to read:
Subd. 4b. [CREDENTIALING.] "Credentialing" means the
process of collecting, verifying, and reviewing evidence that
relates to a health care professional's qualifications to
practice the health care profession as a provider within a
specific integrated service network.
Sec. 11. Minnesota Statutes 1994, section 62N.02, is
amended by adding a subdivision to read:
Subd. 4c. [CREDENTIALING STANDARDS.] An integrated service
network may set credentialing standards for providers. A
network may recredential providers on a recurring basis. If a
network sets credentialing standards, the network must provide a
written description of those standards upon request. An
integrated service network may participate in a centralized
credentialing program and must provide a written description of
that program upon request.
Sec. 12. Minnesota Statutes 1994, section 62N.04, is
amended to read:
62N.04 [REGULATION.]
Integrated service networks are under the supervision of
the commissioner, who shall enforce this chapter, and the
requirements of chapter 62Q as they apply to these networks.
The commissioner has, with respect to this chapter and chapter
62Q, all enforcement and rulemaking powers available to the
commissioner under section 62D.17.
Sec. 13. [62N.071] [DEFINITIONS.]
Subdivision 1. [APPLICABILITY.] The definitions in this
section apply to sections 62N.071 to 62N.078. Unless otherwise
specified, terms used in those sections have the meanings
required to be used in preparation of the National Association
of Insurance Commissioners (NAIC) annual statement blanks for
health maintenance organizations.
Subd. 2. [ADMITTED ASSETS.] "Admitted assets" means
admitted assets as defined under section 62D.044, including the
deposit required under section 62N.074.
Subd. 3. [NET WORTH.] "Net worth" means admitted assets
minus liabilities.
Subd. 4. [LIABILITIES.] "Liabilities" means a network's
debts and other obligations, including estimates of the
network's reported and unreported claims incurred for covered
services and supplies provided to enrollees. Liabilities do not
include those obligations that are subordinated in the same
manner as preferred ownership claims under section 60B.44,
subdivision 10, including promissory notes subordinated to all
other liabilities of the integrated service network.
Subd. 5. [UNCOVERED EXPENDITURES.] "Uncovered expenditures"
means the charges for health care services and supplies that are
covered by an integrated service network for which an enrollee
would also be liable if the network becomes insolvent.
Uncovered expenditures includes charges for covered health care
services and supplies received by enrollees from providers that
are not employed by, under contract with, or otherwise
affiliated with the network. Uncovered expenditures does not
include amounts that enrollees would not have to pay due to the
obligations being guaranteed, insured, or assumed by a person
other than the network.
Subd. 6. [WORKING CAPITAL.] "Working capital" means
current assets minus current liabilities.
Sec. 14. [62N.072] [NET WORTH REQUIREMENT.]
Subdivision 1. [INITIAL REQUIREMENT.] An integrated
service network must, at time of licensure, have a minimum net
worth of the greater of:
(1) $1,500,000; or
(2) 8-1/3 percent of the sum of all expenses expected to be
incurred in the first full year of operation, less 90 percent of
the expected reinsurance premiums for that period.
Subd. 2. [ONGOING REQUIREMENT.] After a network's initial
year of operation, the network must maintain net worth of no
less than $1,000,000 or 8-1/3 percent of the previous years'
expenditures, whichever is greater.
Sec. 15. [62N.073] [DEPOSIT REQUIREMENT.]
Subdivision 1. [INITIAL DEPOSIT.] An integrated service
network shall deposit, at time of licensure, a deposit
consisting of cash and direct United States Treasury obligations
in the total amount of not less than $300,000.
Subd. 2. [CUSTODIAL ACCOUNT.] The deposit must be held in
a custodial or other controlled account under a written account
agreement acceptable to the commissioner.
Subd. 3. [ONGOING DEPOSIT.] After the initial year of
operation, the required amount of the deposit is the greater of
(1) $300,000; or
(2) 33-1/3 percent of the network's uncovered expenditures
incurred in the previous calendar year.
Subd. 4. [USE OF DEPOSIT.] (a) In the event of any
delinquency proceeding as defined in section 60B.03, the
required minimum deposit shall be applied first to pay for or
reimburse the commissioner for expenses incurred by the
commissioner in performing the commissioner's duties in
connection with the insolvency, including any legal, actuarial
or accounting fees. The balance of the required minimum
deposit, if any, shall be used to reimburse enrollees for
uncovered expenditures, on a pro rata basis.
(b) If a deposit exceeds the required minimum deposit, the
excess shall be applied first to uncovered expenditures and the
balance, if any, to the commissioner's expenses.
(c) The deposit is not subject to garnishment or levy under
any circumstances.
Subd. 5. [ACTUAL DEPOSIT REQUIRED.] The deposit must be in
the form specified in subdivision 1; a guarantee or letter of
credit are not acceptable, in whole or in part, as substitutes.
Sec. 16. [62N.074] [WORKING CAPITAL.]
Subdivision 1. [REQUIREMENT.] An integrated service
network must maintain a positive working capital at all times.
Subd. 2. [NOTICE REQUIRED.] If an integrated service
network's working capital is no longer positive, or is likely to
soon become no longer positive, the network shall immediately
notify the commissioner.
Subd. 3. [PLAN OF CORRECTION.] If at any time an
integrated service network's net worth, working capital,
investments, deposits, or guarantees do not conform with the
provisions of this chapter, the network shall promptly submit to
the commissioner a written proposed plan of correction. The
commissioner shall promptly approve, approve as modified, or
reject the proposed plan. If a plan of correction has been
approved by the commissioner, the network shall comply with it
and shall cooperate fully with any activities the commissioner
undertakes to monitor the network's compliance.
Subd. 4. [ACTION BY COMMISSIONER.] The commissioner may
take any action permitted to the commissioner that the
commissioner deems necessary or appropriate to protect the
network or its enrollees if:
(1) the network fails to propose an approved plan of
correction promptly;
(2) the network fails to comply with an approved plan of
correction; or
(3) the commissioner determines that a deficiency in
working capital cannot be corrected within a reasonable time.
Subd. 5. [OTHER REMEDIES.] This section does not limit the
commissioner's power to use at any time other remedies available
to the commissioner.
Sec. 17. [62N.076] [INVESTMENT RESTRICTIONS.]
Subdivision 1. [INVESTMENT POLICY.] An integrated service
network shall have a written investment policy to govern
investment of the network's assets. The written policy must be
reviewed and approved annually by the network's board of
directors.
Subd. 2. [APPROVAL; INVESTMENTS.] A network shall not make
loans or investments, unless authorized by its board of
directors, or ratified by the board no later than the next
regular board meeting.
Subd. 3. [PERMITTED INVESTMENT.] An integrated service
network shall make investments only in securities or property
designated by law as permitted for domestic life insurance
companies; this restriction includes compliance with percentage
limitations that apply to domestic life insurance companies. A
network may, however, invest in real estate, including leasehold
improvements, for the convenience and accommodation of its
operations, including the home office, branch offices, medical
facilities, and field operations, in excess of the percentage
permitted for a domestic life insurance company, but not to
exceed 25 percent of its total admitted assets.
Subd. 4. [CONFLICTS OF INTEREST.] An integrated service
network shall not make loans to any of its directors or
principal officers or make loans to or investments in any
organization in which a director or principal officer has an
interest.
Subd. 5. [PROOF OF COMPLIANCE.] An integrated service
network shall annually file with the commissioner proof of
compliance with this section in a form and on a date prescribed
by the commissioner.
Sec. 18. [62N.077] [USE OF GUARANTEES.]
Subdivision 1. [GUARANTEE PERMITTED.] An integrated
service network may, with the consent of the commissioner,
satisfy up to 50 percent of its minimum net worth requirement by
means of a guarantee provided by another organization.
Subd. 2. [SECURITY FOR GUARANTEE.] (a) If the guaranteeing
organization is regulated for solvency by the commissioner of
commerce or health, the guarantee must be treated as a liability
for purposes of solvency regulation of the guaranteeing
organization. If the guaranteeing organization becomes
insolvent, a claim by the network on the guarantee must be at
least of equal priority with claims of enrollees or other policy
holders of the insolvent guaranteeing organization.
(b) If the guaranteeing organization is not regulated for
solvency by the commissioner of commerce or health, the
organization must maintain assets, except if, when calculated in
combination with the assets described in section 62D.044, clause
(17), the total of those assets and the real estate assets
described in this subdivision do not exceed the total combined
percent limitations allowable under this section and section
62D.044, clause (17), or except if permitted by the commissioner
upon a finding that the percentage of the integrated service
network's admitted assets is insufficient to provide convenient
accommodation of the network's business acceptable to the
commissioner, with a market value at least equal to the amount
of the guarantee, in a custodial or other controlled account on
terms acceptable to the commissioner of health.
Subd. 3. [GOVERNMENTAL ENTITIES.] When a guaranteeing
organization is a governmental entity, sections 62N.073 and
62N.076 do not apply. The commissioner may consider factors
which provide evidence that the governmental entity is a
financially reliable guaranteeing organization.
Sec. 19. [62N.078] [FINANCIAL REPORTING AND EXAMINATION.]
Subdivision 1. [FINANCIAL STATEMENTS.] An integrated
service network shall file with the commissioner, annually on
April 1, an audited financial statement. The financial
statement must include the National Association of Insurance
Commissioners (NAIC) annual statement blanks for health
maintenance organizations, prepared in accordance with the NAIC
annual statement instructions, and using the methods prescribed
in the NAIC's accounting practices and procedures manual for
health maintenance organizations. The financial statement must
also include any other form or information prescribed by the
commissioner.
Subd. 2. [QUARTERLY STATEMENTS.] An integrated service
network shall file with the commissioner quarterly financial
statements for the first three quarters of each year, on a date
and form and in a manner prescribed by the commissioner.
Subd. 3. [OTHER INFORMATION.] An integrated service
network shall comply promptly and fully with requests by the
commissioner for other information that the commissioner deems
necessary to monitor or assess the network's financial solvency.
Subd. 4. [FINANCIAL EXAMINATION.] The commissioner shall
conduct a complete financial examination of each integrated
service network at least once every three years, and more
frequently if the commissioner deems it necessary. The
examinations must be conducted according to the standards
provided in the NAIC examiners handbook.
Sec. 20. Minnesota Statutes 1994, section 62N.10, is
amended by adding a subdivision to read:
Subd. 7. [DATA SUBMISSION.] As a condition of licensure,
an integrated service network shall comply fully with section
62J.38.
Sec. 21. Minnesota Statutes 1994, section 62N.11,
subdivision 1, is amended to read:
Subdivision 1. [APPLICABILITY.] Every integrated service
network enrollee residing in this state is entitled to evidence
of coverage or contract. The integrated service network or its
designated representative shall issue the evidence of coverage
or contract. The commissioner shall adopt rules specifying the
requirements for contracts and evidence of coverage. "Evidence
of coverage" means evidence that an enrollee is covered by a
group contract issued to the group. The evidence of coverage
must contain a description of provider locations, a list of the
types of providers available, and information about the types of
allied and midlevel practitioners and pharmacists that are
available.
Sec. 22. Minnesota Statutes 1994, section 62N.13, is
amended to read:
62N.13 [ENROLLEE COMPLAINT SYSTEM.]
Every integrated service network must establish and
maintain an enrollee complaint system, including an impartial
arbitration provision as required under section 62Q.105, to
provide reasonable procedures for the resolution of written
complaints initiated by enrollees concerning the provision of
health care services. The integrated service network must
inform enrollees that they may choose to use an alternative
dispute resolution process. If an enrollee chooses to use an
alternative dispute resolution process, the network must
participate. The commissioner shall adopt rules specifying
requirements relating to enrollee complaints.
Sec. 23. Minnesota Statutes 1994, section 62N.14,
subdivision 3, is amended to read:
Subd. 3. [ENROLLEE MEMBERSHIP CARDS.] Integrated service
networks shall issue enrollee membership cards to each enrollee
of the integrated service network. The enrollee card shall
contain, at minimum, the following information:
(1) the telephone number of the integrated service
network's office of consumer services;
(2) the address, telephone number, and a brief description
of the state's office of consumer information clearinghouse; and
(3) the telephone number of the department of health or
local ombudsperson.
The membership cards shall also conform to the requirements
set forth in section 62J.60.
Sec. 24. [62N.15] [PROVIDER REQUIREMENTS.]
Subdivision 1. [SERVICES.] An integrated service network
may operate as a staff model as defined in section 295.50,
subdivision 12b, or may contract with providers or provider
organizations for the provision of services.
Subd. 2. [LOCATION.] (a) An integrated service network
must ensure that primary care providers, including allied
independent health providers as defined in section 62Q.095,
subdivision 5, midlevel practitioners as defined in section
136A.1356, subdivision 1, are located at adequate locations
within the service area of the network. In determining whether
locations are adequate, the integrated service network may
consider the practice and referral patterns in each community
served throughout the service area.
(b) Urgent and emergency care providers must be located
within a distance of 30 miles or a travel time of 30 minutes
from every enrollee.
Subd. 3. [NUMBERS.] An integrated service network must
provide a sufficient number of providers to meet the projected
needs of its enrollees, including special needs and high-risk
enrollees, for all covered health care services.
Subd. 4. [TYPES.] An integrated service network must
determine what types of providers are needed to deliver all
appropriate and necessary health services to its enrollees. In
determining which types of providers are necessary, networks
shall use allied and midlevel practitioners and pharmacists
within their respective scopes of practice.
Subd. 5. [CAPACITY.] An integrated service network shall
monitor the capacity of the network to provide services to
enrollees and take steps to increase capacity when parts of the
network are not able to meet enrollee needs.
Subd. 6. [ACCESS.] (a) An integrated service network shall
make available and accessible all covered health care services
on a 24-hour per day, seven days per week basis. This
requirement may be fulfilled through the use of:
(1) regularly scheduled appointments;
(2) after-hour clinics;
(3) use of a 24-hour answering service;
(4) backup coverage by another participating physician; or
(5) referrals to urgent care centers and to hospital
emergency care.
(b) An integrated service network shall arrange for covered
health care services, including referrals to specialty
physicians, to be accessible to enrollees on a timely basis in
accordance with medically appropriate guidelines. An integrated
service network shall have appointment scheduling guidelines
based on the type of health care service.
(c) Nothing in this act shall be construed to require the
creation or maintenance of abortion clinics or other abortion
providers within any integrated service network; nor shall
anything in this act be construed to authorize any agency to
require the creation or maintenance of abortion clinics or
abortion providers or to deny certification or any other benefit
granted by this act to a health plan company based on the number
of or the presence or absence of abortion clinics or other
abortion providers in or affiliated with the health plan company.
Subd. 7. [CONTINUITY.] (a) An integrated service network
shall provide continuing care for enrollees in the event of
contract termination between the integrated service network and
any of its contracted providers or in the event of site closings
involving a provider with more than one location of service.
(b) An integrated service network shall provide to its
enrollees a written disclosure of the process by which
continuity of care will be provided to all enrollees.
Subd. 8. [REVIEW.] The commissioner shall review each
network's compliance with subdivisions 1 to 7. If the
commissioner determines that a network is not meeting the
requirements of this section, the commissioner may order the
network to submit a plan of corrective action, and may order the
network to comply with the provisions of that plan, as amended
by the commissioner.
Sec. 25. [62N.17] [OUT-OF-NETWORK SERVICES.]
(a) An integrated service network shall provide coverage
for all emergency services provided outside the network, when
the care is immediately necessary or believed to be necessary to
preserve life, prevent impairment of bodily functions, or to
prevent placing the physical or mental health of the enrollee in
jeopardy.
(b) An integrated service network shall include in its
marketing materials a description of all limitations of coverage
for out-of-network services, including when enrollees reside or
travel outside the network's service area.
Sec. 26. [62N.18] [QUALITY IMPROVEMENT.]
Subdivision 1. [INTERNAL MEASURES.] Every integrated
service network shall establish and maintain an internal quality
improvement process. A network shall disclose these processes
to enrollees, and to the commissioner upon request.
Subd. 2. [ENROLLEE SURVEYS.] (a) Every integrated service
network shall, on at least a biennial basis, survey enrollee
satisfaction with network performance and quality of care, and
shall make survey results available to enrollees and potential
enrollees. Integrated service networks shall also submit survey
results to the information clearinghouse.
(b) Every integrated service network shall participate in
the consumer survey efforts established under section 62J.451,
subdivision 6b, to evaluate enrollee satisfaction, network
performance, and quality of care. Participation in the consumer
survey efforts of section 62J.451, subdivision 6b, shall satisfy
paragraph (a) of this subdivision.
Subd. 3. [QUALITY IMPROVEMENT WORKPLANS.] (a) An
integrated service network shall submit annual quality
improvement workplans to the commissioner. A workplan must:
(1) identify the four most common enrollee complaints
related to service delivery and the four most common enrollee
complaints related to administration;
(2) identify the specific measures that the network plans
to take to address each of these complaint areas;
(3) provide an assessment of how these complaints affect
health care outcomes; and
(4) identify the mechanisms that the network will use to
communicate and implement the changes needed to address each of
these complaints identified in clause (1).
(b) An integrated service network shall disclose in
marketing materials the complaints identified in paragraph (a),
and measures that will be taken by the network to address these
complaints.
Sec. 27. Minnesota Statutes 1994, section 62N.25,
subdivision 2, is amended to read:
Subd. 2. [LICENSURE REQUIREMENTS GENERALLY.] To be
licensed and to operate as a community integrated service
network, an applicant must satisfy the requirements of chapter
62D, and all other legal requirements that apply to entities
licensed under chapter 62D, except as exempted or modified in
this section. Community networks must, as a condition of
licensure, comply with rules adopted under section 256B.0644
that apply to entities governed by chapter 62D. A community
integrated service network that phases in its net worth over a
three-year period is not required to respond to requests for
proposals under section 256B.0644 during the first 12 months of
licensure. These community networks are not prohibited from
responding to requests for proposals, however, if they choose to
do so during that time period. After the initial 12 months of
licensure, these community networks are required to respond to
the requests for proposals as required under section 256B.0644.
Sec. 28. [62N.40] [CHEMICAL DEPENDENCY SERVICES.]
Each community integrated service network and integrated
service network regulated under this chapter must ensure that
chemically dependent individuals have access to cost-effective
treatment options that address the specific needs of
individuals. These include, but are not limited to, the need
for: treatment that takes into account severity of illness and
comorbidities; provision of a continuum of care, including
treatment and rehabilitation programs licensed under Minnesota
Rules, parts 9530.4100 to 9530.4410 and 9530.5000 to 9530.6500;
the safety of the individual's domestic and community
environment; gender appropriate and culturally appropriate
programs; and access to appropriate social services.
Sec. 29. [REPEALER.]
Minnesota Statutes 1994, section 62N.34, is repealed.
ARTICLE 2
MODIFICATIONS OF REQUIREMENTS FOR HEALTH PLAN COMPANIES
Section 1. Minnesota Statutes 1994, section 62D.11,
subdivision 1, is amended to read:
Subdivision 1. [ENROLLEE COMPLAINT SYSTEM.] Every health
maintenance organization shall establish and maintain a
complaint system including an impartial arbitration
provision, as required under section 62Q.105 to provide
reasonable procedures for the resolution of written complaints
initiated by enrollees concerning the provision of health care
services. "Provision of health services" includes, but is not
limited to, questions of the scope of coverage, quality of care,
and administrative operations. Arbitration shall be subject to
chapter 572, except (a) in the event that an enrollee elects to
litigate a complaint prior to submission to arbitration, and (b)
no medical malpractice damage claim shall be subject to
arbitration unless agreed to by both parties subsequent to the
event giving rise to the claim. The health maintenance
organization must inform enrollees that they may choose to use
an alternative dispute resolution process. If an enrollee
chooses to use an alternative dispute resolution process, the
health maintenance organization must participate.
Sec. 2. Minnesota Statutes 1994, section 62Q.01,
subdivision 2, is amended to read:
Subd. 2. [COMMISSIONER.] "Commissioner" means the
commissioner of health for purposes of regulating health
maintenance organizations, community integrated service
networks, and integrated service networks, or the commissioner
of commerce for purposes of regulating all other health plan
companies. For all other purposes, "commissioner" means the
commissioner of health.
Sec. 3. Minnesota Statutes 1994, section 62Q.01, is
amended by adding a subdivision to read:
Subd. 2a. [ENROLLEE.] "Enrollee" means a natural person
covered by a health plan and includes an insured, policyholder,
subscriber, contract holder, member, covered person, or
certificate holder.
Sec. 4. Minnesota Statutes 1994, section 62Q.01,
subdivision 3, is amended to read:
Subd. 3. [HEALTH PLAN.] "Health plan" means a health plan
as defined in section 62A.011 or; a policy, contract, or
certificate issued by a community integrated service network; or
an integrated service network; or an all-payer insurer as
defined in section 62P.02.
Sec. 5. Minnesota Statutes 1994, section 62Q.01, is
amended by adding a subdivision to read:
Subd. 5. [MANAGED CARE ORGANIZATION.] "Managed care
organization" means: (1) a health maintenance organization
operating under chapter 62D; (2) a community integrated service
network as defined under section 62N.02, subdivision 4a; (3) an
integrated service network as defined under section 62N.02,
subdivision 8; or (4) an insurance company licensed under
chapter 60A, nonprofit health service plan corporation operating
under chapter 62C, fraternal benefit society operating under
chapter 64B, or any other health plan company, to the extent
that it covers health care services delivered to Minnesota
residents through a preferred provider organization or a network
of selected providers.
Sec. 6. Minnesota Statutes 1994, section 62Q.01, is
amended by adding a subdivision to read:
Subd. 6. [MEDICARE-RELATED COVERAGE.] "Medicare-related
coverage" means a policy, contract, or certificate issued as a
supplement to Medicare, regulated under sections 62A.31 to
62A.44, including Medicare select coverage; policies, contracts,
or certificates that supplement Medicare issued by health
maintenance organizations; or policies, contracts, or
certificates governed by section 1833 (known as "cost" or "HCPP"
contracts) or 1876 (known as "TEFRA" or "risk" contracts) of the
federal Social Security Act, United States Code, title 42,
section 1395, et seq., as amended.
Sec. 7. [62Q.02] [APPLICABILITY OF CHAPTER.]
(a) This chapter applies only to health plans, as defined
in section 62Q.01, and not to other types of insurance issued or
renewed by health plan companies, unless otherwise specified.
(b) This chapter applies to a health plan company only with
respect to health plans, as defined in section 62Q.01, issued or
renewed by the health plan company, unless otherwise specified.
(c) If a health plan company issues or renews health plans
in other states, this chapter applies only to health plans
issued or renewed in this state for Minnesota residents, or to
cover a resident of the state, unless otherwise specified.
Sec. 8. Minnesota Statutes 1994, section 62Q.03,
subdivision 1, is amended to read:
Subdivision 1. [PURPOSE.] Risk adjustment is a vital
element of the state's strategy for achieving a more equitable,
efficient system of health care delivery and financing for all
state residents. The purpose of risk adjustment is to reduce
the effects of risk selection on health insurance premiums by
making monetary transfers from health plan companies that insure
lower risk populations to health plan companies that insure
higher risk populations. Risk adjustment is needed to: achieve
a more equitable, efficient system of health care financing;
remove current disincentives in the health care system to insure
and serve provide adequate access for high risk and special
needs populations; promote fair competition among health plan
companies on the basis of their ability to efficiently and
effectively provide services rather than on the health risk
status of those in a given insurance pool; and help
assure maintain the viability of all health plan companies,
including community integrated service networks by protecting
them from the financial effects of enrolling a disproportionate
number of high risk individuals. It is the commitment of the
state to develop and implement a risk adjustment system by July
1, 1997, and to continue to improve and refine risk adjustment
over time. The process for designing and implementing risk
adjustment shall be open, explicit, utilize resources and
expertise from both the private and public sectors, and include
at least the representation described in subdivision 4. The
process shall take into account the formative nature of risk
adjustment as an emerging science, and shall develop and
implement risk adjustment to allow continual modifications,
expansions, and refinements over time. The process shall have
at least two stages, as described in subdivisions 2 and 3. The
risk adjustment system shall:
(1) possess a reasonable level of accuracy and
administrative feasibility, be adaptable to changes as methods
improve, incorporate safeguards against fraud and manipulation,
and shall neither reward inefficiency nor penalize for
verifiable improvements in health status;
(2) require participation by all health plan companies
providing coverage in the individual, small group, and Medicare
supplement markets;
(3) address unequal distribution of risk between health
plan companies, but shall not address the financing of public
programs or subsidies for low-income people; and
(4) be developed and implemented by the risk adjustment
association with joint oversight by the commissioners of health
and commerce.
Sec. 9. Minnesota Statutes 1994, section 62Q.03, is
amended by adding a subdivision to read:
Subd. 5a. [PUBLIC PROGRAMS.] (a) A separate risk
adjustment system must be developed for state-run public
programs, including medical assistance, general assistance
medical care, and MinnesotaCare. The system must be developed
in accordance with the general risk adjustment methodologies
described in this section, must include factors in addition to
age and sex adjustment, and may include additional demographic
factors, different targeted conditions, and/or different payment
amounts for conditions. The risk adjustment system for public
programs must attempt to reflect the special needs related to
poverty, cultural, or language barriers and other needs of the
public program population.
(b) The commissioners of health and human services shall
jointly convene a public programs risk adjustment work group
responsible for advising the commissioners in the design of the
public programs risk adjustment system. The commissioner of
health shall work with the risk adjustment association to ensure
coordination between the risk adjustment systems for the public
and private sectors. The commissioner of human services shall
seek any needed federal approvals necessary for the inclusion of
the medical assistance program in the public program risk
adjustment system.
(c) The public programs risk adjustment work group must be
representative of the persons served by publicly paid health
programs and providers and health plans that meet their needs.
To the greatest extent possible, the appointing authorities
shall attempt to select representatives that have historically
served a significant number of persons in publicly paid health
programs or the uninsured. Membership of the work group shall
be as follows:
(1) one provider member appointed by the Minnesota Medical
Association;
(2) two provider members appointed by the Minnesota
Hospital Association, at least one of whom must represent a
major disproportionate share hospital;
(3) five members appointed by the Minnesota Council of
HMOs, one of whom must represent an HMO with fewer than 50,000
enrollees located outside the metropolitan area and one of whom
must represent an HMO with at least 50 percent of total
membership enrolled through a public program;
(4) two representatives of counties appointed by the
Association of Minnesota Counties;
(5) three representatives of organizations representing the
interests of families, children, childless adults, and elderly
persons served by the various publicly paid health programs
appointed by the governor;
(6) two representatives of persons with mental health,
developmental or physical disabilities, chemical dependency, or
chronic illness appointed by the governor; and
(7) three public members appointed by the governor, at
least one of whom must represent a community health board. The
risk adjustment association may appoint a representative, if a
representative is not otherwise appointed by an appointing
authority.
(d) The commissioners of health and human services, with
the advice of the public programs risk adjustment work group,
shall develop a work plan and time frame and shall coordinate
their efforts with the private sector risk adjustment
association's activities and other state initiatives related to
public program managed care reimbursement. The commissioners of
health and human services shall report to the health care
commission and to the appropriate legislative committees on
January 15, 1996, and on January 15, 1997, on any policy or
legislative changes necessary to implement the public program
risk adjustment system.
Sec. 10. Minnesota Statutes 1994, section 62Q.03, is
amended by adding a subdivision to read:
Subd. 5b. [MEDICARE SUPPLEMENT MARKET.] A risk adjustment
system may be developed for the Medicare supplement market. The
Medicare supplement risk adjustment system may include a
demographic component and may, but is not required to, include a
condition-specific risk adjustment component.
Sec. 11. Minnesota Statutes 1994, section 62Q.03,
subdivision 6, is amended to read:
Subd. 6. [CREATION OF RISK ADJUSTMENT ASSOCIATION.] The
Minnesota risk adjustment association is created on July 1,
1994, and may operate as a nonprofit unincorporated
association., but is authorized to incorporate under chapter
317A.
The provisions of this chapter govern if the provisions of
chapter 317A conflict with this chapter. The association may
operate under the approved plan of operation and shall be
governed in accordance with this chapter and may operate in
accordance with chapter 317A. If the association incorporates
as a nonprofit corporation under chapter 317A, the filing of the
plan of operation meets the requirements of filing articles of
incorporation.
The association, its transactions, and all property owned
by it are exempt from taxation under the laws of this state or
any of its subdivisions, including, but not limited to, income
tax, sales tax, use tax, and property tax. The association may
seek exemption from payment of all fees and taxes levied by the
federal government. Except as otherwise provided in this
chapter, the association is not subject to the provisions of
chapters 14, 60A, 62A, and 62P. The association is not a public
employer and is not subject to the provisions of chapters 179A
and 353. The board of directors and health carriers who are
members of the association are exempt from sections 325D.49 to
325D.66 in the performance of their duties as directors and
members of the association. The risk adjustment association is
subject to the open meeting law.
Sec. 12. Minnesota Statutes 1994, section 62Q.03,
subdivision 7, is amended to read:
Subd. 7. [PURPOSE OF ASSOCIATION.] The association is
established to carry out the purposes of subdivision 1, as
further elaborated on by the implementation report described in
subdivision 5 and by legislation enacted in 1995 or subsequently.
established to develop and implement a private sector risk
adjustment system.
Subject to state oversight set forth in subdivision 10, the
association shall:
(1) develop and implement comprehensive risk adjustment
systems for individual, small group, and Medicare Supplement
markets consistent with the provisions of this chapter;
(2) submit a plan for the development of the risk
adjustment system which identifies appropriate implementation
dates consistent with the rating and underwriting restrictions
of each market, recommends whether transfers attributable to
risk adjustment should be required between the individual and
small group markets, and makes other appropriate recommendations
to the commissioners of health and commerce by November 5, 1995;
(3) develop a combination of a demographic risk adjustment
system and payments for targeted conditions;
(4) test an ambulatory care groups (ACGs) and diagnostic
cost groups (DCGs) system, and recommend whether such a
methodology should be adopted;
(5) fund the development and testing of the risk adjustment
system;
(6) recommend market conduct guidelines; and
(7) develop a plan for assessing members for the costs of
administering the risk adjustment system.
Sec. 13. Minnesota Statutes 1994, section 62Q.03,
subdivision 8, is amended to read:
Subd. 8. [GOVERNANCE.] (a) The association shall be
governed by an interim 19-member board as follows: one provider
member appointed by the Minnesota Hospital Association; one
provider member appointed by the Minnesota Medical Association;
one provider member appointed by the governor; three members
appointed by the Minnesota Council of HMOs to include an HMO
with at least 50 percent of total membership enrolled through a
public program; three members appointed by Blue Cross and Blue
Shield of Minnesota, to include a member from a Blue Cross and
Blue Shield of Minnesota affiliated health plan with fewer than
50,000 enrollees and located outside the Minneapolis-St. Paul
metropolitan area; two members appointed by the Insurance
Federation of Minnesota; one member appointed by the Minnesota
Association of Counties; and three public members appointed by
the governor, to include at least one representative of a public
program. The commissioners of health, commerce, human services,
and employee relations shall be nonvoting ex officio members.
(b) The board may elect officers and establish committees
as necessary.
(c) A majority of the members of the board constitutes a
quorum for the transaction of business.
(d) Approval by a majority of the board members present is
required for any action of the board.
(e) Interim board members shall be appointed by July 1,
1994, and shall serve until a new board is elected according to
the plan of operation developed by the association.
(f) A member may designate a representative to act as a
member of the interim board in the member's absence.
Sec. 14. Minnesota Statutes 1994, section 62Q.03, is
amended by adding a subdivision to read:
Subd. 8a. [PLAN OF OPERATION.] The board shall submit a
proposed plan of operation by August 15, 1995, to the
commissioners of health and commerce for review. The
commissioners of health and commerce shall have the authority to
approve or reject the plan of operation.
Amendments to the plan of operation may be made by the
commissioners or by the directors of the association, subject to
the approval of the commissioners.
Sec. 15. Minnesota Statutes 1994, section 62Q.03,
subdivision 9, is amended to read:
Subd. 9. [DATA COLLECTION AND DATA PRIVACY.] The board of
the association shall consider antitrust implications and
establish procedures to assure that pricing and other
competitive information is appropriately shared among
competitors in the health care market or members of the board.
Any information shared shall be distributed only for the
purposes of administering or developing any of the tasks
identified in subdivisions 2 and 4. In developing these
procedures, the board of the association may consider the
identification of a state agency or other appropriate third
party to receive information of a confidential or competitive
nature. The association members shall not have access to
unaggregated data on individuals or health plan companies. The
association shall develop, as a part of the plan of operation,
procedures for ensuring that data is collected by an appropriate
entity. The commissioners of health and commerce shall have the
authority to audit and examine data collected by the association
for the purposes of the development and implementation of the
risk adjustment system. Data on individuals obtained for the
purposes of risk adjustment development, testing, and operation
are designated as private data. Data not on individuals which
is obtained for the purposes of development, testing, and
operation of risk adjustment are designated as nonpublic data.
Except for the proposed and approved plan of operation, the risk
adjustment methodologies examined, the plan for testing, the
plan of the risk adjustment system, minutes of meetings, and
other general operating information are classified as public
data. Nothing in this section is intended to prohibit the
preparation of summary data under section 13.05, subdivision 7.
The association, state agencies, and any contractors having
access to this data shall maintain it in accordance with this
classification. The commissioners of health and human services
have the authority to collect data from health plan companies as
needed for the purpose of developing a risk adjustment mechanism
for public programs.
Sec. 16. Minnesota Statutes 1994, section 62Q.03,
subdivision 10, is amended to read:
Subd. 10. [SUPERVISION STATE OVERSIGHT OF RISK ADJUSTMENT
ACTIVITIES.] The association's activities shall be supervised by
the commissioners of health and commerce. The commissioners
shall provide specific oversight functions during the
development and implementation phases of the risk adjustment
system as follows:
(1) the commissioners shall approve or reject the
association's plan for testing risk adjustment methods, the
methods to be used, and any changes to those methods;
(2) the commissioners must have the right to attend and
participate in all meetings of the association and its work
groups or committees, except for meetings involving privileged
communication between the association and its counsel as
permitted under section 471.705, subdivision 1d, paragraph (e);
(3) the commissioners shall approve any consultants or
administrators used by the association;
(4) the commissioners shall approve or reject the
association's plan of operation; and
(5) the commissioners shall approve or reject the plan for
the risk adjustment system described in subdivision 7, clause
(2).
If the commissioners reject any of the plans identified in
clauses (1), (4), and (5) of this subdivision, the directors
shall submit for review an appropriate revised plan within 30
days.
Sec. 17. Minnesota Statutes 1994, section 62Q.03, is
amended by adding a subdivision to read:
Subd. 12. [PARTICIPATION BY ALL HEALTH PLAN
COMPANIES.] Upon its implementation, all health plan companies,
as a condition of licensure, must participate in the risk
adjustment system to be implemented under this section.
Sec. 18. Minnesota Statutes 1994, section 62Q.07,
subdivision 1, is amended to read:
Subdivision 1. [ACTION PLANS REQUIRED.] (a) To increase
public awareness and accountability of health plan companies,
all health plan companies that issue or renew a health plan, as
defined in section 62Q.01, must annually file with the
applicable commissioner an action plan that satisfies the
requirements of this section beginning July 1, 1994, as a
condition of doing business in Minnesota. For purposes of this
subdivision, "health plan" includes the coverages described in
section 62A.011, subdivision 3, clause (10). Each health plan
company must also file its action plan with the information
clearinghouse. Action plans are required solely to provide
information to consumers, purchasers, and the larger community
as a first step toward greater accountability of health plan
companies. The sole function of the commissioner in relation to
the action plans is to ensure that each health plan company
files a complete action plan, that the action plan is truthful
and not misleading, and that the action plan is reviewed by
appropriate community agencies.
(b) If a commissioner responsible for regulating a health
plan company required to file an action plan under this section
has reason to believe an action plan is false or misleading, the
commissioner may conduct an investigation to determine whether
the action plan is truthful and not misleading, and may require
the health plan company to submit any information that the
commissioner reasonably deems necessary to complete the
investigation. If the commissioner determines that an action
plan is false or misleading, the commissioner may require the
health plan company to file an amended plan or may take any
action authorized under chapter 72A.
Sec. 19. Minnesota Statutes 1994, section 62Q.07,
subdivision 2, is amended to read:
Subd. 2. [CONTENTS OF ACTION PLANS.] (a) An action plan
must include a detailed description of all of the health plan
company's methods and procedures, standards, qualifications,
criteria, and credentialing requirements for designating the
providers who are eligible to participate in the health plan
company's provider network, including any limitations on the
numbers of providers to be included in the network. This
description must be updated by the health plan company and filed
with the applicable agency on a quarterly basis.
(b) An action plan must include the number of full-time
equivalent physicians, by specialty, nonphysician providers, and
allied health providers used to provide services. The action
plan must also describe how the health plan company intends to
encourage the use of nonphysician providers, midlevel
practitioners, and allied health professionals, through at least
consumer education, physician education, and referral and
advisement systems. The annual action plan must also include
data that is broken down by type of provider, reflecting actual
utilization of midlevel practitioners and allied professionals
by enrollees of the health plan company during the previous
year. Until July 1, 1995, a health plan company may use
estimates if actual data is not available. For purposes of this
paragraph, "provider" has the meaning given in section 62J.03,
subdivision 8.
(c) An action plan must include a description of the health
plan company's policy on determining the number and the type of
providers that are necessary to deliver cost-effective health
care to its enrollees. The action plan must also include the
health plan company's strategy, including provider recruitment
and retention activities, for ensuring that sufficient providers
are available to its enrollees.
(d) An action plan must include a description of actions
taken or planned by the health plan company to ensure that
information from report cards, outcome studies, and complaints
is used internally to improve quality of the services provided
by the health plan company.
(e) An action plan must include a detailed description of
the health plan company's policies and procedures for enrolling
and serving high risk and special needs populations. This
description must also include the barriers that are present for
the high risk and special needs population and how the health
plan company is addressing these barriers in order to provide
greater access to these populations. "High risk and special
needs populations" includes, but is not limited to, recipients
of medical assistance, general assistance medical care, and
MinnesotaCare; persons with chronic conditions or disabilities;
individuals within certain racial, cultural, and ethnic
communities; individuals and families with low income;
adolescents; the elderly; individuals with limited or no English
language proficiency; persons with high-cost preexisting
conditions; homeless persons; chemically dependent persons;
persons with serious and persistent mental illness and; children
with severe emotional disturbance; and persons who are at high
risk of requiring treatment. The action plan must also reflect
actual utilization of providers by enrollees defined by this
section as high risk or special needs populations during the
previous year. For purposes of this paragraph, "provider" has
the meaning given in section 62J.03, subdivision 8.
(f) An action plan must include a general description of
any action the health plan company has taken and those it
intends to take to offer health coverage options to rural
communities and other communities not currently served by the
health plan company.
(g) A health plan company other than a large managed care
plan company may satisfy any of the requirements of the action
plan in paragraphs (a) to (f) by stating that it has no
policies, procedures, practices, or requirements, either written
or unwritten, or formal or informal, and has undertaken no
activities or plans on the issues required to be addressed in
the action plan, provided that the statement is truthful and not
misleading. For purposes of this paragraph, "large managed care
plan company" means a health maintenance organization,
integrated service network, or other health plan company that
employs or contracts with health care providers, that has more
than 50,000 enrollees in this state. If a health plan company
employs or contracts with providers for some of its health plans
and does not do so for other health plans that it offers, the
health plan company is a large managed care plan company if it
has more than 50,000 enrollees in this state in health plans for
which it does employ or contract with providers.
Sec. 20. Minnesota Statutes 1994, section 62Q.09,
subdivision 3, is amended to read:
Subd. 3. [ENFORCEMENT.] Either The commissioner
commissioners of health or and commerce shall each periodically
review contracts among health care providing entities and health
plan companies to determine compliance with this section, with
respect to health plan companies that the commissioners
respectively regulate. Any provider may submit a contract to
the relevant commissioner for review if the provider believes
this section has been violated. Any provision of a contract
found by the relevant commissioner to violate this section is
null and void, and the relevant commissioner may seek assess
civil penalties against the health plan company in an amount not
to exceed $25,000 for each such contract, using the enforcement
procedures otherwise available to the commissioner involved.
Sec. 21. [62Q.105] [HEALTH PLAN COMPANY COMPLAINT
PROCEDURE.]
Subdivision 1. [ESTABLISHMENT.] Each health plan company
shall establish and make available to enrollees, by July 1,
1997, an informal complaint resolution process that meets the
requirements of this section. A health plan company must make
reasonable efforts to resolve enrollee complaints, and must
inform complainants in writing of the company's decision within
30 days of receiving the complaint. The complaint resolution
process must treat the complaint and information related to it
as required under sections 72A.49 to 72A.505.
Subd. 2. [MEDICALLY URGENT COMPLAINTS.] Health plan
companies shall make reasonable efforts to resolve medically
urgent enrollee complaints within 72 hours of receiving the
complaint.
Subd. 3. [APPEALS PROCESS.] Health plan companies shall
establish and make available to enrollees an impartial appeals
process. If a decision by a health plan company regarding a
complaint is partially or wholly adverse to the complainant, the
health plan company shall advise the complainant of the right to
appeal through the impartial appeals process or to the
commissioner.
Subd. 4. [ALTERNATIVE DISPUTE RESOLUTION.] Health plan
companies shall make available to enrollees an alternative
dispute resolution process, and shall participate in alternative
dispute resolution at the request of an enrollee, as required
under section 62Q.11. A health plan company may meet the
requirements of subdivision 3 by providing an alternative
dispute resolution process. If the health plan company chooses
to provide alternative dispute resolution to meet the
requirements of subdivision 3, the process shall be provided at
no cost to the enrollee.
Subd. 5. [REQUIREMENTS FOR MANAGED CARE
ORGANIZATIONS.] Each managed care organization shall submit all
health care quality related complaints to its quality review
board or quality review organization for evaluation and possible
action. The complaint resolution process for managed care
organizations must clearly indicate the entity responsible for
resolving complaints made by enrollees against hospitals, other
health care facilities, and health care providers, that are
owned by or under contract with the managed care organization.
Subd. 6. [RECORD KEEPING.] Health plan companies shall
maintain records of all enrollee complaints and their
resolutions. These records must be retained for five years, and
must be made available to the appropriate commissioner upon
request.
Subd. 7. [REPORTING.] Each health plan company shall
submit to the appropriate commissioner, as part of the company's
annual filing, data on the number and type of complaints that
are not resolved within 30 days. A health plan company shall
also make this information available to the public upon request.
Subd. 8. [NOTICE TO ENROLLEES.] Health plan companies
shall provide a clear and complete description of their
complaint resolution procedures to enrollees as part of their
evidence of coverage or contract. The description must
specifically inform enrollees:
(1) how to file a complaint with the health plan company;
(2) how to request an impartial appeal;
(3) that they have the right to request the use of
alternative methods of dispute resolution; and
(4) that they have the right to litigate.
Sec. 22. [62Q.1055] [CHEMICAL DEPENDENCY.]
All health plan companies shall use the assessment criteria
in Minnesota Rules, parts 9530.6600 to 9530.6660, when assessing
and placing enrollees for chemical dependency treatment.
Sec. 23. [62Q.106] [DISPUTE RESOLUTION BY COMMISSIONER.]
A complainant may at any time submit a complaint to the
appropriate commissioner to investigate. After investigating a
complaint, or reviewing a company's decision, the appropriate
commissioner may order a remedy as authorized under section
62N.04, 62Q.30, chapter 45, 60A, or 62D.
Sec. 24. Minnesota Statutes 1994, section 62Q.11,
subdivision 2, is amended to read:
Subd. 2. [REQUIREMENTS.] (a) If an enrollee, health care
provider, or applicant for network provider status chooses to
use a dispute resolution process prior to the filing of a formal
claim or of a lawsuit, the health plan company must participate.
(b) If an enrollee, health care provider, or applicant for
network provider status chooses to use a dispute resolution
process after the filing of a lawsuit, the health plan company
must participate in dispute resolution, including, but not
limited to, alternative dispute resolution under rule 114 of the
Minnesota general rules of practice.
(c) The commissioners of health and commerce shall inform
and educate health plan companies' enrollees about dispute
resolution and its benefits, and shall establish appropriate
cost-sharing requirements for parties taking part in alternative
dispute resolution.
(d) A health plan company may encourage but not require an
enrollee to submit a complaint to alternative dispute resolution.
Sec. 25. [62Q.145] [ABORTION AND SCOPE OF PRACTICE.]
Health plan company policies related to scope of practice
for allied independent health providers as defined in section
62Q.095, subdivision 5, midlevel practitioners as defined in
section 136A.1356, subdivision 1, and other nonphysician health
care professionals must comply with the requirements governing
the performance of abortions in section 145.412, subdivision 1.
Sec. 26. Minnesota Statutes 1994, section 62Q.19, is
amended to read:
62Q.19 [ESSENTIAL COMMUNITY PROVIDERS.]
Subdivision 1. [DESIGNATION.] The commissioner shall
designate essential community providers. The criteria for
essential community provider designation shall be the following:
(1) a demonstrated ability to integrate applicable
supportive and stabilizing services with medical care for
uninsured persons and high-risk and special needs populations as
defined in section 62Q.07, subdivision 2, paragraph (e),
underserved, and other special needs populations; and
(2) a commitment to serve low-income and underserved
populations by meeting the following requirements:
(i) has nonprofit status in accordance with chapter 317A;
(ii) has tax exempt status in accordance with the Internal
Revenue Service Code, section 501(c)(3);
(iii) charges for services on a sliding fee schedule based
on current poverty income guidelines; and
(iv) does not restrict access or services because of a
client's financial limitation; or
(3) status as a local government unit as defined in section
62D.02, subdivision 11, an Indian tribal government, an Indian
health service unit, or community health board as defined in
chapter 145A.
Prior to designation, the commissioner shall publish the
names of all applicants in the State Register. The public shall
have 30 days from the date of publication to submit written
comments to the commissioner on the application. No designation
shall be made by the commissioner until the 30-day period has
expired.
The commissioner may designate an eligible provider as an
essential community provider for all the services offered by
that provider or for specific services designated by the
commissioner.
For the purpose of this subdivision, supportive and
stabilizing services include at a minimum, transportation, child
care, cultural, and linguistic services where appropriate.
Subd. 2. [APPLICATION.] (a) Any provider may apply to the
commissioner for designation as an essential community
provider by submitting an application form developed by the
commissioner. Applications must be accepted within two years
after the effective date of the rules adopted by the
commissioner to implement this section.
(b) Each application submitted must be accompanied by an
application fee in an amount determined by the commissioner.
The fee shall be no more than what is needed to cover the
administrative costs of processing the application.
(c) The name, address, contact person, and the date by
which the commissioner's decision is expected to be made shall
be classified as public data under section 13.41. All other
information contained in the application form shall be
classified as private data under section 13.41 until the
application has been approved, approved as modified, or denied
by the commissioner. Once the decision has been made, all
information shall be classified as public data unless the
applicant designates and the commissioner determines that the
information contains trade secret information.
Subd 2a. [DEFINITION OF HEALTH PLAN COMPANY.] For purposes
of this section, "health plan company" does not include a health
plan company as defined in section 62Q.01 with fewer than 50,000
enrollees, all of whose enrollees are covered under medical
assistance, general assistance medical care, or MinnesotaCare.
Subd. 3. [HEALTH PLAN COMPANY AFFILIATION.] A health plan
company must offer a provider contract to any designated
essential community provider located within the area served by
the health plan company. A health plan company shall not
restrict enrollee access to services designated to be provided
by the essential community provider for the population that the
essential community provider is certified to serve. A health
plan company may also make other providers available to this
same population for these services. A health plan company may
require an essential community provider to meet all data
requirements, utilization review, and quality assurance
requirements on the same basis as other health plan providers.
Subd. 4. [ESSENTIAL COMMUNITY PROVIDER RESPONSIBILITIES.]
Essential community providers must agree to serve enrollees of
all health plan companies operating in the area that in which
the essential community provider is certified to serve located.
Subd. 5. [CONTRACT PAYMENT RATES.] An essential community
provider and a health plan company may negotiate the payment
rate for covered services provided by the essential community
provider. This rate must be competitive with rates paid to
other health plan providers the same rate per unit of service as
is paid to other health plan providers for the same or similar
services.
Subd. 5a. [COOPERATION.] Each health plan company and
essential community provider shall cooperate to facilitate the
use of the essential community provider by the high risk and
special needs populations. This includes cooperation on the
submission and processing of claims, sharing of all pertinent
records and data, including performance indicators and specific
outcomes data, and the use of all dispute resolution methods as
defined in section 62Q.11, subdivision 1.
Subd. 5b. [ENFORCEMENT.] For any violation of this section
or any rule applicable to an essential community provider, the
commissioner may suspend, modify, or revoke an essential
community provider designation. The commissioner may also use
the enforcement authority specified in section 62D.17.
Subd. 6. [TERMINATION.] The designation as an essential
community provider is terminated terminates five years after it
is granted, and or when universal coverage as defined under
section 62Q.165 is achieved, whichever is later. Once the
designation terminates, the former essential community provider
has no rights or privileges beyond those of any other health
care provider. The commissioner shall make a recommendation to
the legislature on whether an essential community provider
designation should be longer than five years.
Subd. 7. [RECOMMENDATIONS AND RULEMAKING ON ESSENTIAL
COMMUNITY PROVIDERS.] (a) As part of the implementation plan due
January 1, 1995, the commissioner shall present proposed rules
and any necessary recommendations for legislation for defining
essential community providers, using the criteria established
under subdivision 1, and defining the relationship between
essential community providers and health plan companies.
(b) By January 1, 1996, the commissioner shall adopt rules
for establishing essential community providers and for governing
their relationship with health plan companies. The commissioner
shall also identify and address any conflict of interest issues
regarding essential community provider designation for local
governments. The rules shall require health plan companies to
comply with all provisions of section 62Q.14 with respect to
enrollee use of essential community providers.
Sec. 27. [62Q.43] [GEOGRAPHIC ACCESS.]
Subdivision 1. [CLOSED-PANEL HEALTH PLAN.] For purposes of
this section, "closed-panel health plan" means a health plan as
defined in section 62Q.01 that requires an enrollee to receive
all or a majority of primary care services from a specific
clinic or physician designated by the enrollee that is within
the health plan company's clinic or physician network.
Subd. 2. [ACCESS REQUIREMENT.] Every closed-panel health
plan must allow enrollees who are full-time students under the
age of 25 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. [62Q.45] [COVERAGE FOR OUT-OF-AREA PRIMARY CARE.]
Subdivision 1. [STUDY.] The commissioner of health shall
develop methods to allow enrollees of managed care organizations
to obtain primary care health services outside of the service
area of their managed care organization, from health care
providers who are employed by or under contract with another
managed care organization. The commissioner shall make
recommendations on: (1) whether this out-of-area primary care
coverage should be available to students and/or other enrollees
without additional premium charges or cost sharing; (2) methods
to coordinate the services provided by different managed care
organizations; (3) methods to manage the quality of care
provided by different managed care organizations and monitor
health care outcomes; (4) methods to reimburse managed care
organizations for care provided to enrollees of other managed
care organizations; and (5) other issues relevant to the design
and administration of out-of-area primary care coverage. The
commissioner shall present recommendations to the legislature by
January 15, 1996.
Subd. 2. [DEFINITION.] For purposes of this section,
"managed care organization" means: (1) a health maintenance
organization operating under chapter 62D; (2) a community
integrated service network as defined under section 62N.02,
subdivision 4a; (3) an integrated service network as defined
under section 62N.02, subdivision 8; or (4) an insurance company
licensed under chapter 60A, nonprofit health service plan
corporation operating under chapter 62C, fraternal benefit
society operating under chapter 64B, or any other health plan
company, to the extent that it covers health care services
delivered to Minnesota residents through a preferred provider
organization or a network of selected providers.
Sec. 29. [62Q.47] [MENTAL HEALTH AND CHEMICAL DEPENDENCY
SERVICES.]
(a) All health plans, as defined in section 62Q.01, that
provide coverage for mental health or chemical dependency
services, must comply with the requirements of this section.
(b) Cost-sharing requirements and benefit or service
limitations for outpatient mental health and outpatient chemical
dependency services, except for persons placed in chemical
dependency services under Minnesota Rules, parts 9530.6600 to
9530.6660, must not place a greater financial burden on the
insured or enrollee, or be more restrictive than those
requirements and limitations for outpatient medical services.
(c) Cost-sharing requirements and benefit or service
limitations for inpatient hospital mental health and inpatient
hospital and residential chemical dependency services, except
for persons placed in chemical dependency services under
Minnesota Rules, parts 9530.6600 to 9530.6660, must not place a
greater financial burden on the insured or enrollee, or be more
restrictive than those requirements and limitations for
inpatient hospital medical services.
Sec. 30. Minnesota Statutes 1994, section 145.414, is
amended to read:
145.414 [ABORTION NOT MANDATORY.]
(a) No person and no hospital or institution shall be
coerced, held liable or discriminated against in any manner
because of a refusal to perform, accommodate, assist or submit
to an abortion for any reason.
(b) It is the policy of the state of Minnesota that no
health plan company as defined under section 62Q.01, subdivision
4, or health care cooperative as defined under section 62R.04,
subdivision 2, shall be required to provide or provide coverage
for an abortion. No provision of this chapter; of chapter 62A,
62C, 62D, 62H, 62L, 62M, 62N, 62R, 64B, or of any other chapter;
of Minnesota Rules; or of this act shall be construed as
requiring a health plan company as defined under section 62Q.01,
subdivision 4, or a health care cooperative as defined under
section 62R.04, subdivision 2, to provide or provide coverage
for an abortion.
(c) This section supersedes any provision of this act, or
any act enacted prior to enactment of this act, that in any way
limits or is inconsistent with this section. No provision of
any act enacted subsequent to this act shall be construed as in
any way limiting or being inconsistent with this section, unless
the act amends this section or expressly provides that it is
intended to limit or be inconsistent with this section.
Sec. 31. [SINGLE ENTRY POINT FOR COMPLAINTS.]
The commissioner of health shall establish a single entry
point within the health department for consumer complaints about
the quality and cost of health care services, whether these
services are delivered by individual providers, health care
facilities, or health plan companies. The commissioner shall
present a work plan to the legislature by February 1, 1996.
Sec. 32. [CHEMICAL DEPENDENCY STANDARDS AND INCENTIVES.]
Subdivision 1. [STANDARDS.] As part of the department of
human service's household survey of chemical dependency needs in
Minnesota, the commissioner of human services shall study
whether utilization standards pertaining to the number of
chemical dependency treatment inpatient and outpatient referrals
per 1,000 enrollees and lengths of stay are needed for the state
to address chemical dependency treatment needs.
Subd. 2. [INCENTIVES SYSTEM.] The commissioners of human
services and health shall develop recommendations for a
financial or other incentive system for health plan companies to
meet the standards developed in subdivision 1. The
commissioners shall report to the health care commission and
appropriate legislative committees by January 15, 1997.
Sec. 33. [CONSTRUCTION.]
Nothing in this act shall be construed to expand existing
law with respect to coverage of abortion.
Sec. 34. [STUDY OF HEALTH CARE DELIVERY.]
The Minnesota health care commission shall study the impact
of managed care and other methods of health care delivery on the
quality of life and care provided to terminally ill patients.
The commission shall also study the impact of managed care and
other methods of health care delivery on the quality of life and
care provided to persons with chronic illness or disability.
The commission shall hold hearings at various sites in Minnesota
and take testimony from concerned citizens. The commission
shall present a report on these issues to the legislature and
the governor by December 15, 1996.
Sec. 35. [REPEALER; HMO ARBITRATION RULES.]
Minnesota Rules, part 4685.1700, subpart 1, item D, is
repealed.
Sec. 36. [REPEALER.]
Minnesota Statutes 1994, sections 62Q.03, subdivisions 2,
3, 4, 5, and 11; 62Q.21; and 62Q.27, are repealed.
Sec. 37. [EFFECTIVE DATE.]
Sections 1, 31, and 36 are effective January 1, 1996.
Section 27 is effective July 1, 1995, and applies to
closed-panel health plans offered, sold, issued, or renewed on
or after that date.
Section 29 is effective August 1, 1995, and applies to
health plans offered, issued, or renewed on or after that date.
ARTICLE 3
REGULATED ALL-PAYER OPTION
Section 1. Minnesota Statutes 1994, section 62J.017, is
amended to read:
62J.017 [IMPLEMENTATION TIMETABLE.]
The state seeks to complete the restructuring of the health
care delivery and financing system by July 1, 1997. The
restructured system will have two options: (1) integrated
service networks, which will be accountable for meeting state
cost containment, quality, and access standards; or (2) a
uniform set of price and utilization controls for all health
care services for Minnesota residents not provided through an
integrated service network. Both systems will operate under the
state's growth limits and will be structured to promote
competition in the health care marketplace. Beginning July 1,
1994, measures will be taken to increase the public
accountability of existing health plan companies, to promote the
development of small, community-based integrated service
networks, and to reduce administrative costs by standardizing
third-party billing forms and procedures and utilization review
requirements. Voluntary formation of other integrated service
networks will begin after rules have been adopted, but not
before July 1, 1996. Statutes and rules for the entire
restructured health care financing and delivery system must be
enacted or adopted by January 1, 1996, and a phase-in of the
all-payer reimbursement system must begin on that date. By July
1, 1997, all health coverage must be regulated under integrated
service network or community integrated service network law
pursuant to chapter 62N or all-payer law pursuant to chapter 62P.
Sec. 2. Minnesota Statutes 1994, section 62J.04,
subdivision 1a, is amended to read:
Subd. 1a. [ADJUSTED GROWTH LIMITS AND ENFORCEMENT.] (a)
The commissioner shall publish the final adjusted growth limit
in the State Register by January 31 of the year that the
expenditure limit is to be in effect. The adjusted limit must
reflect the actual regional consumer price index for urban
consumers for the previous calendar year, and may deviate from
the previously published projected growth limits to reflect
differences between the actual regional consumer price index for
urban consumers and the projected Consumer Price Index for urban
consumers. The commissioner shall report to the legislature by
February 15 of each year on the implementation of the growth
limits. This annual report shall describe the differences
between the projected increase in health care expenditures, the
actual expenditures based on data collected, and the impact and
validity of growth limits within the overall health care reform
strategy.
(b) The commissioner, in consultation with the Minnesota
health care commission, shall research and include in the annual
report required in paragraph (a) for 1996, recommendations
regarding the implementation of growth limits for health plan
companies and providers. The commissioner shall:
(1) consider both spending and revenue approaches and
report on the implementation of the interim limits as defined in
sections 62J.041 and 62J.042;
(2) make recommendations regarding the enforcement
mechanism and consider mechanisms to adjust future growth limits
as well as mechanisms to establish financial penalties for
noncompliance;
(3) address the feasibility of systemwide limits imposed on
all integrated service networks; and
(4) make recommendations on the most effective way to
implement growth limits on the fee-for-service system in the
absence of a regulated all-payer system.
(b) (c) The commissioner shall enforce limits on growth in
spending and revenues for integrated service networks and for
the regulated all-payer option health plan companies and
revenues for providers. If the commissioner determines that
artificial inflation or padding of costs or prices has occurred
in anticipation of the implementation of growth limits, the
commissioner may adjust the base year spending totals or growth
limits or take other action to reverse the effect of the
artificial inflation or padding.
(c) (d) The commissioner shall impose and enforce overall
limits on growth in revenues and spending for integrated service
networks health plan companies, with adjustments for changes in
enrollment, benefits, severity, and risks. If an integrated
service network a health plan company exceeds the growth limits,
the commissioner may reduce future limits on growth in aggregate
premium revenues for that integrated service network by up to
the amount overspent. If the integrated service network system
exceeds a systemwide spending limit, the commissioner may reduce
future limits on growth in premium revenues for the integrated
service network system by up to the amount overspent impose
financial penalties up to the amount exceeding the applicable
growth limit.
(d) The commissioner shall set prices, utilization
controls, and other requirements for the regulated all-payer
option to ensure that the overall costs of this system, after
adjusting for changes in population, severity, and risk, do not
exceed the growth limits. If growth limits for a calendar year
are exceeded, the commissioner may reduce reimbursement rates or
otherwise recoup amounts exceeding the limit for all or part of
the next calendar year. To the extent possible, the
commissioner may reduce reimbursement rates or otherwise recoup
amounts over the limit from individual providers who exceed the
growth limits.
(e) The commissioner, in consultation with the Minnesota
health care commission, shall research and make recommendations
to the legislature regarding the implementation of growth limits
for integrated service networks and the regulated all-payer
option. The commissioner must consider both spending and
revenue approaches and will report on the implementation of the
interim limits as defined in sections 62P.04 and 62P.05. The
commissioner must examine and make recommendations on the use of
annual update factors based on volume performance standards as a
mechanism for achieving controls on spending in the all-payer
option. The commissioner must make recommendations regarding
the enforcement mechanism and must consider mechanisms to adjust
future growth limits as well as mechanisms to establish
financial penalties for noncompliance. The commissioner must
also address the feasibility of systemwide limits imposed on all
integrated service networks.
(f) The commissioner shall report to the legislative
commission on health care access by December 1, 1994, on trends
in aggregate spending and premium revenue for health plan
companies. The commissioner shall use data submitted under
section 62P.04 and other available data to complete this report.
Sec. 3. Minnesota Statutes 1994, section 62J.09,
subdivision 1a, is amended to read:
Subd. 1a. [DUTIES RELATED TO COST CONTAINMENT.] (a) [
ALLOCATION OF REGIONAL SPENDING LIMITS.] Regional coordinating
boards may advise the commissioner regarding allocation of
annual regional limits on the rate of growth for providers in
the regulated all-payer option in order to:
(1) achieve communitywide and regional public health goals
consistent with those established by the commissioner; and
(2) promote access to and equitable reimbursement of
preventive and primary care providers.
(b) [TECHNICAL ASSISTANCE.] Regional coordinating boards,
in cooperation with the commissioner, shall provide technical
assistance to parties interested in establishing or operating a
community integrated service network or integrated service
network within the region. This assistance must complement
assistance provided by the commissioner under section 62N.23.
Sec. 4. Minnesota Statutes 1994, section 62J.152,
subdivision 5, is amended to read:
Subd. 5. [USE OF TECHNOLOGY EVALUATION.] (a) The final
report on the technology evaluation and the commission's
comments and recommendations may be used:
(1) by the commissioner in retrospective and prospective
review of major expenditures;
(2) by integrated service networks and other group
purchasers and by employers, in making coverage, contracting,
purchasing, and reimbursement decisions;
(3) by government programs and regulators of the regulated
all-payer option, in making coverage, contracting, purchasing,
and reimbursement decisions;
(4) by the commissioner and other organizations in the
development of practice parameters;
(5) (4) by health care providers in making decisions about
adding or replacing technology and the appropriate use of
technology;
(6) (5) by consumers in making decisions about treatment;
(7) (6) by medical device manufacturers in developing and
marketing new technologies; and
(8) (7) as otherwise needed by health care providers,
health care plans, consumers, and purchasers.
(b) At the request of the commissioner, the health care
commission, in consultation with the health technology advisory
committee, shall submit specific recommendations relating to
technologies that have been evaluated under this section for
purposes of retrospective and prospective review of major
expenditures and coverage, contracting, purchasing, and
reimbursement decisions affecting state programs and the
all-payer option.
Sec. 5. Minnesota Statutes 1994, section 62Q.01,
subdivision 4, is amended to read:
Subd. 4. [HEALTH PLAN COMPANY.] "Health plan company"
means:
(1) a health carrier as defined under section 62A.011,
subdivision 2;
(2) an integrated service network as defined under section
62N.02, subdivision 8; or
(3) an all-payer insurer as defined under section 62P.02;
or
(4) a community integrated service network as defined under
section 62N.02, subdivision 4a.
Sec. 6. Minnesota Statutes 1994, section 62Q.30, is
amended to read:
62Q.30 [EXPEDITED FACT FINDING AND DISPUTE RESOLUTION
PROCESS.]
The commissioner shall establish an expedited fact finding
and dispute resolution process to assist enrollees of integrated
service networks and all-payer insurers health plan companies
with contested treatment, coverage, and service issues to be in
effect July 1, 1997. The commissioner may order an integrated
service network or an all-payer insurer to provide or pay for a
service that is within the universal standard benefits set
health coverage. If the disputed issue relates to whether a
service is appropriate and necessary, the commissioner shall
issue an order only after consulting with appropriate experts
knowledgeable, trained, and practicing in the area in dispute,
reviewing pertinent literature, and considering the availability
of satisfactory alternatives. The commissioner shall take steps
including but not limited to fining, suspending, or revoking the
license of an integrated service network or an all-payer insurer
a health plan company that is the subject of repeated orders by
the commissioner that suggests a pattern of inappropriate
underutilization.
Sec. 7. Minnesota Statutes 1994, section 62Q.41, is
amended to read:
62Q.41 [ANNUAL IMPLEMENTATION REPORT.]
(a) The commissioner of health, in consultation with the
Minnesota health care commission, shall develop an annual
implementation report to be submitted to the legislature each
year beginning January 1, 1995, describing the progress and
status of rule development and implementation of the integrated
service network system and the regulated all-payer option, and
providing recommendations for legislative changes that the
commissioner determines may be needed.
(b) As part of the report required in paragraph (a) due for
1996, the commissioner, in consultation with the health care
commission, shall make recommendations on the design and
development of an appropriate framework to apply regulations
uniformly among all health plan companies and to ensure adequate
oversight and consumer protection in the absence of a regulated
all-payer system.
Sec. 8. Laws 1994, chapter 625, article 5, section 5,
subdivision 1, is amended to read:
Subdivision 1. [PROPOSED LEGISLATION.] The commissioners
of health and commerce, in consultation with the Minnesota
health care commission and the legislative commission on health
care access, shall draft proposed legislation to recodify,
simplify, and standardize all statutes, rules, regulatory
requirements, and procedures relating to health plan companies.
The recodification and regulatory reform must become effective
simultaneously with the full implementation of the integrated
service network system and the regulated all-payer option on
July 1, 1997. The commissioners of health and commerce shall
submit to the legislature by January 1, 1996, a report on the
recodification and regulatory reform with proposed legislation.
Sec. 9. [INSTRUCTION TO REVISOR; RECODIFICATION OF INTERIM
LIMITS.]
The revisor of statutes shall recode Minnesota Statutes,
section 62P.04, as amended, as section 62J.041, and shall recode
section 62P.05, as amended, as section 62J.042.
Sec. 10. [REPEALER.]
Minnesota Statutes 1994, sections 62J.152, subdivision 6;
62P.01; 62P.02; 62P.03; 62P.07; 62P.09; 62P.11; 62P.13; 62P.15;
62P.17; 62P.19; 62P.21; 62P.23; 62P.25; 62P.27; 62P.29; 62P.31;
and 62P.33, are repealed.
ARTICLE 4
UNIVERSAL COVERAGE
Section 1. Minnesota Statutes 1994, section 62Q.165, is
amended to read:
62Q.165 [UNIVERSAL COVERAGE.]
Subdivision 1. [DEFINITION.] It is the commitment of the
state to achieve universal health coverage for all
Minnesotans by July 1, 1997. In order to achieve this
commitment, the following goals must be met:
(1) every Minnesotan shall have health coverage and shall
contribute to the costs of coverage based on ability to pay;
(2) no Minnesotan shall be denied coverage or forced to pay
more because of health status;
(3) quality health care services must be accessible to all
Minnesotans;
(4) all health care purchasers must be placed on an equal
footing in the health care marketplace; and
(5) a comprehensive and affordable health plan must be
available to all Minnesotans. Universal coverage is achieved
when:
(1) every Minnesotan has access to a full range of quality
health care services;
(2) every Minnesotan is able to obtain affordable health
coverage which pays for the full range of services, including
preventive and primary care; and
(3) every Minnesotan pays into the health care system
according to that person's ability.
Subd. 2. [GOAL.] It is the goal of the state to make
continuous progress toward reducing the number of Minnesotans
who do not have health coverage so that by January 1, 2000,
fewer than four percent of the state's population will be
without health coverage. The goal will be achieved by improving
access to private health coverage through insurance reforms and
market reforms, by making health coverage more affordable for
low-income Minnesotans through purchasing pools and state
subsidies, and by reducing the cost of health coverage through
cost containment programs and methods of ensuring that all
Minnesotans are paying into the system according to their
ability.
Subd. 3. [REPORT ON HEALTH CARE ACCESS.] (a) The health
care commission shall annually report to the legislature
regarding the extent to which the state is making progress
toward the goal of universal coverage described in this
section. As part of this report, the commission shall monitor
the number of uninsured in the state. The annual report must be
submitted no later than January 15 of each year in compliance
with section 3.195.
(b) The annual report required under paragraph (a), due
January 15, 1996, shall advise the legislature regarding
possible additional steps in insurance reform that would be
helpful in progressing toward universal coverage. The
commission shall consider further initiatives involving group
purchasing pools, narrowing premium variations, guaranteed issue
and portability requirements, preexisting condition limitations,
and other provisions that provide greater opportunities to
obtain affordable health coverage. The commission shall
consider the small employer reforms contained in the model laws
recommended by the National Association of Insurance
Commissioners and shall recommend whether these reforms should
be adopted.
(c) The annual report due required under paragraph (a),
required on January 15, 1996, shall advise the legislature
regarding possible changes in the individual insurance market.
The report shall consider initiatives regarding purchasing
pools, including specific design details of a state-run or
state-initiated purchasing pool for individuals, specific
legislative reforms needed to encourage the formation of
purchasing pools, and point-by-point consideration of the
obstacles to enactment of these purchasing pools, including
adverse selection. The report shall consider the creation of a
standard and objective definition of eligibility for the
comprehensive health association, and whether the enactment of
such a definition could be coupled with guaranteed issuance for
the remainder of the individual market. The report should
include all other considerations of the commission as to the
optimal reforms of the individual market.
(d) The health care commission shall in its annual report
make recommendations regarding any steps toward achieving
universal coverage that became feasible as a result of changes
in federal law that remove barriers to state efforts to expand
health care access.
(e) To the extent possible, the health care commission
shall utilize existing information, including information
collected by other state or federal agencies and organizations,
to complete the studies and reports in this subdivision. State
agencies and organizations shall provide information, technical
and analytic support, and other assistance to the commission as
possible, to ensure the timely and efficient completion of the
studies and reports in this subdivision. Staff from the
appropriate state agencies shall participate with the commission
executive director no later than June 15 each year in initial
planning and coordination for the annual reports and studies of
this subdivision. Following this initial planning, the
executive director shall report to the legislative oversight
commission on health care access by July 1 each year on the
initial study plan, and on any commission tasks or studies which
may not be completed as scheduled due to such constraints as
lack of sufficient available information or resources.
Sec. 2. Minnesota Statutes 1994, section 62Q.18, is
amended to read:
62Q.18 [UNIVERSAL PORTABILITY OF COVERAGE; INSURANCE
REFORMS.]
Subdivision 1. [DEFINITION.] For purposes of this section,
(1) "continuous coverage" has the meaning given in section
62L.02;
(2) "guaranteed issue" means:
(i) for individual health plans, that a health plan company
shall not decline an application by an individual for any
individual health plan offered by that health plan company,
including coverage for a dependent of the individual to whom the
health plan has been or would be issued; and
(ii) for group health plans, that a health plan company
shall not decline an application by a group for any group health
plan offered by that health plan company and shall not decline
to cover under the group health plan any person eligible for
coverage under the group's eligibility requirements, including
persons who become eligible after initial issuance of the group
health plan; and
(3) "qualifying coverage" has the meaning given in section
62L.02; and
(4) "underwriting restrictions" has the meaning given in
section 62L.03, subdivision 4.
Subd. 2. [INDIVIDUAL MANDATE.] Effective July 1, 1997,
each Minnesota resident shall obtain and maintain qualifying
coverage.
Subd. 3. [GUARANTEED ISSUE.] (a) Effective July 1, 1997,
each health plan company shall offer, sell, issue, or renew each
of its individual health plan forms on a guaranteed issue basis
to any Minnesota resident.
(b) Effective July 1, 1997, each health plan company shall
offer, sell, issue, or renew each of its group health plan forms
to any employer that has its principal place of business in this
state on a guaranteed issue basis, provided that the guaranteed
issue requirement does not apply to employees, dependents, or
other persons to be covered, who are not residents of this state.
Subd. 4. [UNDERWRITING RESTRICTIONS LIMITED.] Effective
July 1, 1997, no health plan company shall offer, sell, issue,
or renew a health plan that has underwriting restrictions that
apply to a Minnesota resident, except as expressly permitted
under this section.
Subd. 5. [PREEXISTING CONDITION LIMITATIONS.] Effective
July 1, 1997, no health plan company shall offer, sell, issue,
or renew a health plan that contains a preexisting condition
limitation or exclusion or exclusionary rider that applies to a
Minnesota resident, except a limitation which is no longer than
12 months and applies only to a person who has not maintained
continuous coverage. An unexpired preexisting condition
limitation from previous qualifying coverage may be carried over
to new coverage under a health plan, if the unexpired condition
is one permitted under this section. A Minnesota resident who
has not maintained continuous coverage may be subjected to a new
12-month preexisting condition limitation after each break in
continuous coverage.
Subd. 6. [LIMITS ON PREMIUM RATE VARIATIONS.] (a)
Effective July 1, 1995, the premium rate variations permitted
under sections 62A.65 and 62L.08 become:
(1) for factors other than age and geography, 12.5 percent
of the index rate; and
(2) for age, 25 percent of the index rate.
(b) Effective July 1, 1996, the premium variations
permitted under sections 62A.65 and 62L.08 become:
(1) for factors other than age and geography, 7.5 percent
of the index rate; and
(2) for age, 15 percent of the index rate.
(c) Effective July 1, 1997, no health plan company shall
offer, sell, issue, or renew a health plan, that is subject to
section 62A.65 or 62L.08, for which the premium rate varies
between covered persons on the basis of any factor other than:
(1) for individual health plans, differences in benefits or
benefit design, and for group health plans, actuarially valid
differences in benefits or benefit design;
(2) the number of persons to be covered by the health plan;
(3) actuarially valid differences in expected costs between
adults and children;
(4) healthy lifestyle discounts authorized by statute; and
(5) for individual health plans, geographic variations
permitted under section 62A.65, and for group health plans,
geographic variations permitted under section 62L.08.
(d) All premium rate variations permitted under paragraph
(c) are subject to the approval of the commissioner.
(e) Notwithstanding paragraphs (a), (b), and (c), no health
plan company shall renew any individual or group health plan,
except in compliance with this paragraph. No premium rate for
any policy holder or contract holder shall increase or decrease
upon renewal, as a result of this subdivision, by more than 15
percent per year. The increase or decrease described in this
paragraph is in addition to any premium increase or decrease
caused by legally permissible factors other than this
subdivision. If a premium increase or decrease is constrained
by this paragraph, the health plan company may implement the
remaining portion of the increase or decrease at the time of
subsequent annual renewals, but never to exceed 15 percent per
year for paragraphs (a), (b), and (c) combined.
Subd. 7. [PORTABILITY OF COVERAGE.] (a) Effective July 1,
1997, no health plan company shall offer, sell, issue, or renew
any group or individual health plan that does not provide for
guaranteed issue, with full credit for previous qualifying
coverage against any preexisting condition limitation that would
otherwise apply under subdivision 5. No health plan shall be
subject to any other type of underwriting restriction.
(b) Effective July 1, 1995, no health plan company shall
offer, sell, issue, or renew any group or individual health plan
that does not, with respect to individuals who maintain
continuous coverage and whose immediately preceding qualifying
coverage is a health plan issued by medical assistance under
chapter 256B, general assistance medical care under chapter
256D, or the MinnesotaCare program established under section
256.9352,
(1) make coverage available on a guaranteed issue basis;
and
(2) give full credit for previous continuous coverage
against any applicable preexisting condition limitation or
exclusion.
(c) Paragraph (b) applies to individuals whose immediately
preceding qualifying coverage is medical assistance under
chapter 256B, general assistance medical care under chapter
256D, or the MinnesotaCare program established under section
256.9352, only if the individual has disenrolled from the public
program or will disenroll upon issuance of the new coverage.
Paragraph (b) does not apply if the public program uses or will
use public funds to pay the premiums for an individual who
remains or will remain enrolled in the public program. No
public funds may be used to purchase private coverage available
under this paragraph. This paragraph does not prohibit public
payment of premiums to continue private sector coverage
originally obtained prior to enrollment in the public program,
where otherwise permitted by state or federal law. Portability
coverage under this paragraph is subject to the provisions of
section 62A.65, subdivision 5, clause (b).
(d) Effective July 1, 1994, no health plan company shall
offer, sell, issue, or renew any group health plan that does
not, with respect to individuals who maintain continuous
coverage and who qualify under the group's eligibility
requirements:
(1) make coverage available on a guaranteed issue basis;
and
(2) give full credit for previous continuous coverage
against any applicable preexisting condition limitation or
preexisting condition exclusion.
To the extent that this paragraph subdivision conflicts
with chapter 62L, with respect to small employers as defined in
section 62L.02, chapter 62L governs, regardless of whether the
group sponsor is a small employer as defined in section 62L.02,
except that for group health plans issued to groups that are not
small employers, this subdivision's requirement that the
individual have maintained continuous coverage applies. An
individual who has maintained continuous coverage, but would be
considered a late entrant under chapter 62L, may be treated as a
late entrant in the same manner under this subdivision as
permitted under chapter 62L.
Subd. 8. [COMPREHENSIVE HEALTH ASSOCIATION.] Effective
July 1, 1997, the comprehensive health association created in
section 62E.10 shall not accept new applicants for enrollment,
except for Medicare-related coverage described in section 62E.12
and for coverage described in section 62E.18.
Subd. 9. [CONTINGENCY; FUTURE LEGISLATION.] This section,
except for subdivision 7, paragraphs (b), (c), and (d), is not
intended to be implemented prior to legislation enacted to
achieve the objectives of section 62Q.165 and Laws 1994, chapter
625, article 6, sections 5, 6, and 7. Subdivision 6 is not
effective until an effective date is specified in 1995
legislation.
Sec. 3. [COORDINATION BETWEEN ACUTE AND LONG-TERM CARE.]
Subdivision 1. [GOAL.] The health care commission shall
examine the relationship between the acute and long-term care
systems in order to address fragmentation and cost shifting
between these two systems.
Subd. 2. [PLAN.] The commission shall prepare a plan for a
process to bring about greater coordination between acute and
long-term care that would maximize quality, overcome cost
shifting, and contain overall costs.
(a) The commission's plan shall identify:
(1) concepts, issues, perceived problems, or concerns to be
addressed as part of a process to achieve greater coordination
and improved outcomes in acute and long-term care;
(2) a suitable process for addressing the issues in clause
(1), including adequate involvement of appropriate stakeholder
groups, persons receiving long-term care, and the public; and
(3) recommendations for appropriate relationships, division
of responsibilities, resources, and a timetable for the process
of achieving greater coordination between acute and long-term
care.
(b) The commission's plan shall address:
(1) the need for an appropriate framework for measuring and
comparing potential costs and benefits of proposals to improve
coordination between acute and long-term care;
(2) specific information needs and how the information will
be developed or obtained;
(3) the role of the commission and any changes or
modifications of the commission in assisting the process
described in the plan; and
(4) the degree to which the process of coordinating acute
and long-term care might be undertaken sequentially or
incrementally, with descriptions of any recommended steps in the
process.
(c) In developing the plan, the commission shall take
testimony from interested persons, review findings of previous
studies and reports, and consult with other state agencies and
organizations, including, but not limited to:
(1) adults with disabilities, parents or guardians of
children with disabilities, and groups representing children and
adults with a variety of disabilities; and
(2) facility based and home and community-based long-term
care providers.
(d) The commission's plan shall be reported to the
legislature by January 15, 1996.
Sec. 4. [REPEALER; ADDITIONAL INSURANCE REFORMS.]
Minnesota Statutes 1994, section 62Q.18, subdivisions 2, 3,
4, 5, 6, 8, and 9, are repealed.
ARTICLE 5
DATA COLLECTION AND RESEARCH INITIATIVES
Section 1. Minnesota Statutes 1994, section 13.99, is
amended by adding a subdivision to read:
Subd. 115. [HEALTH DATA INSTITUTE DATA.] Data created,
collected, received, maintained, or disseminated by the
Minnesota health data institute established under section
62J.451 are classified under section 62J.452; access to and
disclosure of such data are governed by section 62J.452.
Sec. 2. Minnesota Statutes 1994, section 62J.04,
subdivision 3, is amended to read:
Subd. 3. [COST CONTAINMENT DUTIES.] After obtaining the
advice and recommendations of the Minnesota health care
commission, the commissioner shall:
(1) establish statewide and regional limits on growth in
total health care spending under this section, monitor regional
and statewide compliance with the spending limits, and take
action to achieve compliance to the extent authorized by the
legislature;
(2) divide the state into no fewer than four regions, with
one of those regions being the Minneapolis/St. Paul metropolitan
statistical area but excluding Chisago, Isanti, Wright, and
Sherburne counties, for purposes of fostering the development of
regional health planning and coordination of health care
delivery among regional health care systems and working to
achieve spending limits;
(3) provide technical assistance to regional coordinating
boards;
(4) monitor the quality of health care throughout the
state, conduct consumer satisfaction surveys, and take action as
necessary to ensure an appropriate level of quality;
(5) issue recommendations regarding uniform billing forms,
uniform electronic billing procedures and data interchanges,
patient identification cards, and other uniform claims and
administrative procedures for health care providers and private
and public sector payers. In developing the recommendations,
the commissioner shall review the work of the work group on
electronic data interchange (WEDI) and the American National
Standards Institute (ANSI) at the national level, and the work
being done at the state and local level. The commissioner may
adopt rules requiring the use of the Uniform Bill 82/92 form,
the National Council of Prescription Drug Providers (NCPDP) 3.2
electronic version, the Health Care Financing Administration
1500 form, or other standardized forms or procedures;
(6) undertake health planning responsibilities as provided
in section 62J.15;
(7) monitor and promote the development and implementation
of practice parameters;
(8) authorize, fund, or promote research and
experimentation on new technologies and health care procedures;
(9) designate referral centers for specialized and
high-cost procedures and treatment and establish minimum
standards and requirements for particular procedures or
treatment;
(10) (8) within the limits of appropriations for these
purposes, administer or contract for statewide consumer
education and wellness programs that will improve the health of
Minnesotans and increase individual responsibility relating to
personal health and the delivery of health care services,
undertake prevention programs including initiatives to improve
birth outcomes, expand childhood immunization efforts, and
provide start-up grants for worksite wellness programs; and
(11) administer the data analysis unit; and
(12) (9) undertake other activities to monitor and oversee
the delivery of health care services in Minnesota with the goal
of improving affordability, quality, and accessibility of health
care for all Minnesotans.
Sec. 3. Minnesota Statutes 1994, section 62J.06, is
amended to read:
62J.06 [IMMUNITY FROM LIABILITY.]
No member of the Minnesota health care commission
established under section 62J.05, regional coordinating boards
established under section 62J.09, or the health
planning technology advisory committee established under section
62J.15, data collection advisory committee established under
section 62J.30, or practice parameter advisory committee
established under section 62J.32 shall be held civilly or
criminally liable for an act or omission by that person if the
act or omission was in good faith and within the scope of the
member's responsibilities under this chapter.
Sec. 4. Minnesota Statutes 1994, section 62J.212, is
amended to read:
62J.212 [COLLABORATION ON PUBLIC HEALTH GOALS.]
The commissioner may increase regional spending limits if
public health goals for that region are achieved. The
commissioner shall establish specific public health goals
including, but not limited to, increased delivery of prenatal
care, improved birth outcomes, and expanded childhood
immunizations. The commissioner shall consider the community
public health goals and the input of the statewide advisory
committee on community health in establishing the statewide
goals.
Sec. 5. [62J.2930] [INFORMATION CLEARINGHOUSE.]
Subdivision 1. [ESTABLISHMENT.] The commissioner of health
shall establish an information clearinghouse within the
department of health to facilitate the ability of consumers,
employers, providers, health plan companies, and others to
obtain information on health reform activities in Minnesota.
The commissioner shall make available through the clearinghouse
updates on federal and state health reform activities, including
information developed or collected by the department of health
on cost containment or other research initiatives, the
development of integrated service networks, and voluntary
purchasing pools, action plans submitted by health plan
companies, reports or recommendations of the health technology
advisory committee and other entities on technology assessments,
and reports or recommendations from other formal committees
applicable to health reform activities. The clearinghouse shall
also refer requestors to sources of further information or
assistance. The clearinghouse is subject to chapter 13.
Subd. 2. [INFORMATION ON HEALTH PLAN COMPANIES.] The
information clearinghouse shall provide information on all
health plan companies operating in a specific geographic area to
consumers and purchasers who request it.
Subd. 3. [CONSUMER INFORMATION.] The information
clearinghouse or another entity designated by the commissioner
shall provide consumer information to health plan company
enrollees to:
(1) assist enrollees in understanding their rights;
(2) explain and assist in the use of all available
complaint systems, including internal complaint systems within
health carriers, community integrated service networks,
integrated service networks, and the departments of health and
commerce;
(3) provide information on coverage options in each
regional coordinating board region of the state;
(4) provide information on the availability of purchasing
pools and enrollee subsidies; and
(5) help consumers use the health care system to obtain
coverage.
The information clearinghouse or other entity designated by
the commissioner for the purposes of this subdivision shall not:
(1) provide legal services to consumers;
(2) represent a consumer or enrollee; or
(3) serve as an advocate for consumers in disputes with
health plan companies.
Nothing in this subdivision shall interfere with the ombudsman
program established under section 256B.031, subdivision 6, or
other existing ombudsman programs.
Subd. 4. [COORDINATION.] To the extent possible, the
commissioner shall coordinate the activities of the
clearinghouse with the activities of the Minnesota health data
institute.
Sec. 6. [62J.301] [RESEARCH AND DATA INITIATIVES.]
Subdivision 1. [DEFINITIONS.] For purposes of sections
62J.2930 to 62J.42, the following definitions apply:
(a) "Health outcomes data" means data used in research
designed to identify and analyze the outcomes and costs of
alternative interventions for a given clinical condition, in
order to determine the most appropriate and cost-effective means
to prevent, diagnose, treat, or manage the condition, or in
order to develop and test methods for reducing inappropriate or
unnecessary variations in the type and frequency of
interventions.
(b) "Encounter level data" means data related to the
utilization of health care services by, and the provision of
health care services to individual patients, enrollees, or
insureds, including claims data, abstracts of medical records,
and data from patient interviews and patient surveys.
Subd. 2. [STATEMENT OF PURPOSE.] The commissioner of
health shall conduct data and research initiatives in order to
monitor and improve the efficiency and effectiveness of health
care in Minnesota.
Subd. 3. [GENERAL DUTIES.] The commissioner shall:
(1) collect and maintain data which enable population-based
monitoring and trending of the access, utilization, quality, and
cost of health care services within Minnesota;
(2) collect and maintain data for the purpose of estimating
total Minnesota health care expenditures and trends;
(3) collect and maintain data for the purposes of setting
limits under section 62J.04, and measuring growth limit
compliance;
(4) conduct applied research using existing and new data
and promote applications based on existing research;
(5) develop and implement data collection procedures to
ensure a high level of cooperation from health care providers
and health plan companies, as defined in section 62Q.01,
subdivision 4;
(6) work closely with health plan companies and health care
providers to promote improvements in health care efficiency and
effectiveness; and
(7) participate as a partner or sponsor of private sector
initiatives that promote publicly disseminated applied research
on health care delivery, outcomes, costs, quality, and
management.
Subd. 4. [INFORMATION TO BE COLLECTED.] (a) The data
collected may include health outcomes data, patient functional
status, and health status. The data collected may include
information necessary to measure and make adjustments for
differences in the severity of patient condition across
different health care providers, and may include data obtained
directly from the patient or from patient medical records, as
provided in section 62J.321, subdivision 1.
(b) The commissioner may:
(1) collect the encounter level data required for the
research and data initiatives of sections 62J.301 to 62J.42,
using, to the greatest extent possible, standardized forms and
procedures; and
(2) process the data collected to ensure validity,
consistency, accuracy, and completeness, and as appropriate,
merge data collected from different sources.
(c) For purposes of estimating total health care spending
and forecasting rates of growth in health care spending, the
commissioner may collect from health care providers data on
patient revenues and health care spending during a time period
specified by the commissioner. The commissioner may also
collect data on health care revenues and spending from group
purchasers of health care. Health care providers and group
purchasers doing business in the state shall provide the data
requested by the commissioner at the times and in the form
specified by the commissioner. Professional licensing boards
and state agencies responsible for licensing, registering, or
regulating providers and group purchasers shall cooperate fully
with the commissioner in achieving compliance with the reporting
requirements.
Subd. 5. [NONLIMITING.] Nothing in this chapter shall be
construed to limit the powers granted to the commissioner of
health under chapter 62D, 62N, 144, or 144A.
Sec. 7. [62J.311] [ANALYSIS AND USE OF DATA.]
Subdivision 1. [DATA ANALYSIS.] The commissioner shall
analyze the data collected to:
(1) assist the state in developing and refining its health
policy in the areas of access, utilization, quality, and cost;
(2) assist the state in promoting efficiency and
effectiveness in the financing and delivery of health services;
(3) monitor and track accessibility, utilization, quality,
and cost of health care services within the state;
(4) evaluate the impact of health care reform activities;
(5) assist the state in its public health activities; and
(6) evaluate and determine the most appropriate methods for
ongoing data collection.
Subd. 2. [CRITERIA FOR DATA AND RESEARCH INITIATIVES.] (a)
Data and research initiatives by the commissioner, pursuant to
sections 62J.301 to 62J.42, must:
(1) serve the needs of the general public, public sector
health care programs, employers and other purchasers of health
care, health care providers, including providers serving large
numbers of people with low-income, and health plan companies as
applicable;
(2) be based on scientifically sound and statistically
valid methods;
(3) be statewide in scope, to the extent feasible, in order
to benefit health care purchasers and providers in all parts of
Minnesota and to ensure broad and representative health care
data for research comparisons and applications;
(4) emphasize data that is useful, relevant, and
nonredundant of existing data. The initiatives may duplicate
existing private data collection activities, if necessary to
ensure that the data collected will be in the public domain;
(5) be structured to minimize the administrative burden on
health plan companies, health care providers, and the health
care delivery system, and minimize any privacy impact on
individuals; and
(6) promote continuous improvement in the efficiency and
effectiveness of health care delivery.
(b) Data and research initiatives related to public sector
health care programs must:
(1) assist the state's current health care financing and
delivery programs to deliver and purchase health care in a
manner that promotes improvements in health care efficiency and
effectiveness;
(2) assist the state in its public health activities,
including the analysis of disease prevalence and trends and the
development of public health responses;
(3) assist the state in developing and refining its overall
health policy, including policy related to health care costs,
quality, and access; and
(4) provide data that allows the evaluation of state health
care financing and delivery programs.
Sec. 8. [62J.321] [DATA COLLECTION AND PROCESSING
PROCEDURES.]
Subdivision 1. [DATA COLLECTION.] (a) The commissioner
shall collect data from health care providers, health plan
companies, and individuals in the most cost-effective manner,
which does not unduly burden them. The commissioner may require
health care providers and health plan companies to collect and
provide patient health records and claim files, and cooperate in
other ways with the data collection process. The commissioner
may also require health care providers and health plan companies
to provide mailing lists of patients. Patient consent shall not
be required for the release of data to the commissioner pursuant
to sections 62J.301 to 62J.42 by any group purchaser, health
plan company, health care provider; or agent, contractor, or
association acting on behalf of a group purchaser or health care
provider. Any group purchaser, health plan company, health care
provider; or agent, contractor, or association acting on behalf
of a group purchaser or health care provider, that releases data
to the commissioner in good faith pursuant to sections 62J.301
to 62J.42 shall be immune from civil liability and criminal
prosecution.
(b) When a group purchaser, health plan company, or health
care provider submits patient identifying data, as defined in
section 62J.451, to the commissioner pursuant to sections
62J.301 to 62J.42, and the data is submitted to the commissioner
in electronic form, or through other electronic means including,
but not limited to, the electronic data interchange system
defined in section 62J.451, the group purchaser, health plan
company, or health care provider shall submit the patient
identifying data in encrypted form, using an encryption method
specified by the commissioner. Submission of encrypted data as
provided in this paragraph satisfies the requirements of section
144.335, subdivision 3b.
(c) The commissioner shall require all health care
providers, group purchasers, and state agencies to use a
standard patient identifier and a standard identifier for
providers and health plan companies when reporting data under
this chapter. The commissioner must encrypt patient identifiers
to prevent identification of individual patients and to enable
release of otherwise private data to researchers, providers, and
group purchasers in a manner consistent with chapter 13 and
sections 62J.55 and 144.335. This encryption must ensure that
any data released must be in a form that makes it impossible to
identify individual patients.
Subd. 2. [FAILURE TO PROVIDE DATA.] The intentional
failure to provide the data requested under this chapter is
grounds for disciplinary or regulatory action against a
regulated provider or group purchaser. The commissioner may
assess a fine against a provider or group purchaser who refuses
to provide data required by the commissioner. If a provider or
group purchaser refuses to provide the data required, the
commissioner may obtain a court order requiring the provider or
group purchaser to produce documents and allowing the
commissioner to inspect the records of the provider or group
purchaser for purposes of obtaining the data required.
Subd. 3. [DATA COLLECTION AND REVIEW.] Data collection
must continue for a sufficient time to permit: adequate
analysis by researchers and appropriate providers, including
providers who will be impacted by the data; feedback to
providers; monitoring for changes in practice patterns; and the
data and research criteria of section 62J.311, subdivision 2, to
be fulfilled.
Subd. 4. [USE OF EXISTING DATA.] (a) The commissioner
shall negotiate with private sector organizations currently
collecting health care data of interest to the commissioner to
obtain required data in a cost-effective manner and minimize
administrative costs. The commissioner shall attempt to
establish links between the health care data collected to
fulfill sections 62J.301 to 62J.42 and existing private sector
data and shall consider and implement methods to streamline data
collection in order to reduce public and private sector
administrative costs.
(b) The commissioner shall use existing public sector data,
such as those existing for medical assistance and Medicare, to
the greatest extent possible. The commissioner shall establish
links between existing public sector data and consider and
implement methods to streamline public sector data collection in
order to reduce public and private sector administrative costs.
Subd. 5. [DATA CLASSIFICATION.] (a) Data collected to
fulfill the data and research initiatives authorized by sections
62J.301 to 62J.42 that identify individual patients or providers
are private data on individuals. Data not on individuals are
nonpublic data. The commissioner shall establish procedures and
safeguards to ensure that data released by the commissioner is
in a form that does not identify specific patients, providers,
employers, individual or group purchasers, or other specific
individuals and organizations, except with the permission of the
affected individual or organization, or as permitted elsewhere
in this chapter.
(b) Raw unaggregated data collected from household and
employer surveys used by the commissioner to monitor the number
of uninsured individuals, reasons for lack of insurance
coverage, and to evaluate the effectiveness of health care
reform, are subject to the same data classifications as data
collected pursuant to sections 62J.301 to 62J.42.
(c) Notwithstanding sections 13.03, subdivisions 6 to 8;
13.10, subdivisions 1 to 4; and 138.17, data received by the
commissioner pursuant to sections 62J.301 to 62J.42, shall
retain the classification designated under this section and
shall not be disclosed other than pursuant to this section.
(d) Summary data collected to fulfill the data and research
initiatives authorized by sections 62J.301 to 62J.42 may be
disseminated under section 13.05, subdivision 7. For the
purposes of this section, summary data includes nonpublic data
not on individuals.
(e) Notwithstanding paragraph (a), the commissioner may
publish nonpublic or private data collected pursuant to sections
62J.301 to 62J.42 on health care costs and spending, quality and
outcomes, and utilization for health care institutions,
individual health care professionals and groups of health care
professionals, group purchasers, and integrated service
networks, with a description of the methodology used for
analysis. The commissioner may not make public any patient
identifying information except as specified in law. The
commissioner shall not reveal the name of an institution, group
of professionals, individual health care professional, group
purchaser, or integrated service network until after the
institution, group of professionals, individual health care
professional, group purchaser, or integrated service network has
had 21 days to review the data and comment. The commissioner
shall include comments received in the release of the data.
(f) A provider or group purchaser may contest whether the
data meets the criteria of section 62J.311, subdivision 2,
paragraph (a), clause (2), in accordance with a contested case
proceeding as set forth in sections 14.57 to 14.62, subject to
appeal in accordance with sections 14.63 to 14.68. To obtain a
contested case hearing, the provider or group purchaser must
make a written request to the commissioner before the end of the
time period for review and comment. Within ten days of the
assignment of an administrative law judge, the provider or group
purchaser shall make a clear showing to the administrative law
judge of probable success in a hearing on the issue of whether
the data are accurate and valid and were collected based on the
criteria of section 62J.311, subdivision 2, paragraph (a),
clause (2). If the administrative law judge determines that the
provider or group purchaser has made such a showing, the data
shall remain private or nonpublic during the contested case
proceeding and appeal. If the administrative law judge
determines that the provider or group purchaser has not made
such a showing, the commissioner may publish the data
immediately, with comments received in the release of the data.
The contested case proceeding and subsequent appeal is not an
exclusive remedy and any person may seek a remedy pursuant to
section 13.08, subdivisions 1 to 4, or as otherwise authorized
by law.
Subd. 6. [RULEMAKING.] The commissioner may adopt rules to
implement sections 62J.301 to 62J.452.
Subd. 7. [FEDERAL AND OTHER GRANTS.] The commissioner may
seek federal funding, and funding from private and other
nonstate sources, for data and research initiatives.
Subd. 8. [CONTRACTS AND GRANTS.] To carry out the duties
assigned in sections 62J.301 to 62J.42, the commissioner may
contract with or provide grants to private sector entities. Any
contract or grant must require the private sector entity to
maintain the data which it receives according to the statutory
provisions applicable to the data.
Sec. 9. [62J.322] [PROVIDER INFORMATION PILOT STUDY.]
The commissioner shall develop a pilot study to collect
comparative data from health care providers on opportunities and
barriers to the provision of quality, cost-effective health
care. The provider information pilot study shall include
providers in community integrated service networks, integrated
service networks, health maintenance organizations, preferred
provider organizations, indemnity insurance plans, public
programs, and other health plan companies. Health plan
companies and group purchasers shall provide to the commissioner
providers' names, health plan assignment, and other appropriate
data necessary for the commissioner to conduct the study. The
provider information pilot study shall examine factors that
increase and hinder access to the provision of quality,
cost-effective health care. The study may examine:
(1) administrative barriers and facilitators;
(2) time spent obtaining permission for appropriate and
necessary treatments;
(3) latitude to order appropriate and necessary tests,
pharmaceuticals, and referrals to specialty providers;
(4) assistance available for decreasing administrative and
other routine paperwork activities;
(5) continuing education opportunities provided;
(6) access to readily available information on diagnoses,
diseases, outcomes, and new technologies;
(7) continuous quality improvement activities;
(8) inclusion in administrative decision making;
(9) access to social services and other services that
facilitate continuity of care;
(10) economic incentives and disincentives;
(11) peer review procedures; and
(12) the prerogative to address public health needs.
In selecting additional data for collection, the
commissioner shall consider the: (i) statistical validity of
the data; (ii) public need for the data; (iii) estimated expense
of collecting and reporting the data; and (iv) usefulness of the
data to identify barriers and opportunities to improve quality
care provision within health plan companies.
Sec. 10. Minnesota Statutes 1994, section 62J.37, is
amended to read:
62J.37 [COST CONTAINMENT DATA FROM INTEGRATED SERVICE
NETWORKS.]
The commissioner shall require integrated service networks
operating under section 62N.06, subdivision 1, to submit data on
health care spending and revenue for calendar year 1994 1996 by
February 15, 1995 April 1, 1997. Each February 15 April 1
thereafter, integrated service networks shall submit to the
commissioner data on health care spending and revenue for the
preceding calendar year. The data must be provided in the form
specified by the commissioner. To the extent that an integrated
service network is operated by a group purchaser under section
62N.06, subdivision 2, the integrated service network is exempt
from this section and the group purchaser must provide data on
the integrated service network under section 62J.38.
Sec. 11. Minnesota Statutes 1994, section 62J.38, is
amended to read:
62J.38 [COST CONTAINMENT DATA FROM GROUP PURCHASERS.]
(a) The commissioner shall require group purchasers to
submit detailed data on total health care spending for calendar
years 1990, 1991, and 1992, and for each calendar year 1993 and
successive calendar years. Group purchasers shall submit data
for the 1993 calendar year by April 1, 1994, and each April 1
thereafter shall submit data for the preceding calendar year.
(b) The commissioner shall require each group purchaser to
submit data on revenue, expenses, and member months, as
applicable. Revenue data must distinguish between premium
revenue and revenue from other sources and must also include
information on the amount of revenue in reserves and changes in
reserves. Expenditure data, including raw data from claims,
must may be provided separately for the following categories or
for other categories required by the commissioner: physician
services, dental services, other professional services,
inpatient hospital services, outpatient hospital services,
emergency and out-of-area care, pharmacy services and
prescription drugs other nondurable medical goods, mental health
services, and chemical dependency services, other expenditures,
subscriber liability, and administrative costs. The
commissioner may require each group purchaser to submit any
other data, including data in unaggregated form, for the
purposes of developing spending estimates, setting spending
limits, and monitoring actual spending and costs.
(c) The commissioner may collect information on:
(1) premiums, benefit levels, managed care procedures, and
other features of health plan companies;
(2) prices, provider experience, and other information for
services less commonly covered by insurance or for which
patients commonly face significant out-of-pocket expenses; and
(3) information on health care services not provided
through health plan companies, including information on prices,
costs, expenditures, and utilization.
(c) State agencies and (d) All other group purchasers shall
provide the required data using a uniform format and uniform
definitions, as prescribed by the commissioner.
Sec. 12. Minnesota Statutes 1994, section 62J.40, is
amended to read:
62J.40 [COST CONTAINMENT DATA FROM STATE AGENCIES AND OTHER
GOVERNMENTAL UNITS.]
In addition to providing the data required under section
62J.38, the commissioners of human services, commerce, labor and
industry, and employee relations and (a) All other state
departments or agencies that administer one or more health care
programs shall provide to the commissioner of health any
additional data on the health care programs they administer that
is requested by the commissioner of health, including data in
unaggregated form, for purposes of developing estimates of
spending, setting spending limits, and monitoring actual
spending. The data must be provided at the times and in the
form specified by the commissioner of health.
(b) For purposes of estimating total health care spending
as provided in section 62J.301, subdivision 4, clause (c), all
local governmental units shall provide expenditure data to the
commissioner. The commissioner shall consult with
representatives of the affected local government units in
establishing definitions, reporting formats, and reporting time
frames. As much as possible, the data shall be collected in a
manner that ensures that the data collected is consistent with
data collected from the private sector and minimizes the
reporting burden to local government.
Sec. 13. Minnesota Statutes 1994, section 62J.41,
subdivision 1, is amended to read:
Subdivision 1. [COST CONTAINMENT DATA TO BE COLLECTED FROM
PROVIDERS.] The commissioner shall require health care providers
to collect and provide both patient specific information and
descriptive and financial aggregate data on:
(1) the total number of patients served;
(2) the total number of patients served by state of
residence and Minnesota county;
(3) the site or sites where the health care provider
provides services;
(4) the number of individuals employed, by type of
employee, by the health care provider;
(5) the services and their costs for which no payment was
received;
(6) total revenue by type of payer or by groups of payers,
including but not limited to, revenue from Medicare, medical
assistance, MinnesotaCare, nonprofit health service plan
corporations, commercial insurers, integrated service networks,
health maintenance organizations, and individual patients;
(7) revenue from research activities;
(8) revenue from educational activities;
(9) revenue from out-of-pocket payments by patients;
(10) revenue from donations; and
(11) any other data required by the commissioner, including
data in unaggregated form, for the purposes of developing
spending estimates, setting spending limits, monitoring actual
spending, and monitoring costs and quality.
The commissioner may, by rule, modify the data submission
categories listed above if the commissioner determines that this
will reduce the reporting burden on providers without having a
significant negative effect on necessary data collection efforts.
Sec. 14. Minnesota Statutes 1994, section 62J.41,
subdivision 2, is amended to read:
Subd. 2. [ANNUAL MONITORING AND ESTIMATES.] The
commissioner shall require health care providers to submit the
required data for the period July 1, 1993 to December 31, 1993,
by April 1, 1994. Health care providers shall submit data for
the 1994 calendar year by April 1, 1995, and each April 1
thereafter shall submit data for the preceding calendar year.
The commissioner of revenue may collect health care service
revenue data from health care providers, if the commissioner of
revenue and the commissioner agree that this is the most
efficient method of collecting the data. The commissioner of
revenue shall provide any data collected to the commissioner of
health commissioners of health and revenue shall have the
authority to share data collected pursuant to this section.
Sec. 15. [62J.451] [MINNESOTA HEALTH DATA INSTITUTE.]
Subdivision 1. [STATEMENT OF PURPOSE.] It is the intention
of the legislature to create a partnership between the public
and the private sectors for the coordination of efforts related
to the collection, analysis, and dissemination of cost, access,
quality, utilization, and other performance data, to the extent
administratively efficient and effective.
The Minnesota health data institute shall be a partnership
between the commissioner of health and a board of directors
representing group purchasers, health care providers, and
consumers.
Subd. 2. [DEFINITIONS.] For purposes of this section and
section 62J.452, the following definitions apply.
(a) "Analysis" means the identification of selected data
elements, a description of the methodology used to select or
analyze those data elements, and any other commentary,
conclusions, or other descriptive material that the health data
institute determines is appropriately included, all of which is
undertaken by the health data institute for one or more of the
purposes or objectives set forth in subdivisions 1 and 3, or by
other authorized researchers pursuant to section 62J.452,
subdivision 6.
(b) "Board" means the board of directors of the health data
institute.
(c) "Contractor" means an agent, association, or other
individual or entity that has entered into an agreement with an
industry participant, as defined in section 62J.452, subdivision
2, paragraph (i), to act on behalf of that industry participant
for purposes of fulfilling the data collection and reporting
activities established under this chapter.
(d) "Database" means a compilation of selected data
elements by the health data institute for the purpose of
conducting an analysis or facilitating an analysis by another
party.
(e) "Electronic data interchange system" or "EDI system"
means the electronic data system developed, implemented,
maintained, or operated by the health data institute, as
permitted by subdivisions 3, clause (2), and 5, according to
standards adopted by the health data institute.
(f) "Encounter level data" means data related to the
utilization of health care services by, and the provision of
health care services to, individual patients, enrollees, or
insureds, including claims data, abstracts of medical records,
and data from patient interviews and patient surveys.
(g) "Group purchaser" has the definition provided in
section 62J.03, subdivision 6.
(h) "Health data institute" means the public-private
partnership between the commissioner of health and the board of
directors established under this section.
(i) "Health plan company" has the definition provided in
section 62Q.01, subdivision 4.
(j) "Industry participant" means any group purchaser,
employers with employee health benefit plans, regardless of the
manner in which benefits are provided or paid for under the
plan, provider, or state agency or political subdivision, with
the exception of professional licensing boards or law
enforcement agencies.
(k) "Industry participant identifying data" means any data
that identifies a specific industry participant directly, or
which identifies characteristics which reasonably could uniquely
identify such specific industry participant circumstantially.
For purposes of this definition, an industry participant is not
"directly identified" by the use of a unique identification
number, provided that the number is coded or encrypted through a
reliable system that can reasonably assure that such numbers
cannot be traced back by an unauthorized person to determine the
identity of an industry participant with a particular number.
(l) "Patient" is an individual as defined in section 13.02,
subdivision 8, except that "patient" does not include any
industry participant acting as an industry participant rather
than as a consumer of health care services or coverage.
(m) "Patient identifying data" means data that identifies a
patient directly, or which identifies characteristics which
reasonably could uniquely identify such specific patients
circumstantially. For purposes of this definition, a patient is
not "directly identified" by the use of a unique identification
number, provided that the number is coded or encrypted through a
reliable system that can reasonably assure that such numbers
cannot be traced back by an unauthorized person to determine the
identity of a patient with a particular number.
(n) "Performance" means the degree to which a health plan
company, provider organization, or other entity delivers
quality, cost-effective services compared to other similar
entities, or to a given level of care set as a goal to be
attained.
(o) "Provider" or "health care provider" has the meaning
given in section 62J.03, subdivision 8.
(p) "Roster data" with regard to the enrollee of a health
plan company or group purchaser means an enrollee's name,
address, telephone number, date of birth, gender, and enrollment
status under a group purchaser's health plan. "Roster data"
with regard to a patient of a provider means the patient's name,
address, telephone number, date of birth, gender, and date or
dates treated, including, if applicable, the date of admission
and the date of discharge.
Subd. 3. [OBJECTIVES OF THE HEALTH DATA INSTITUTE.] (a)
The health data institute shall:
(1) develop a data collection plan that provides
coordination for public and private sector data collection
efforts related to the performance measurement and improvement
of the health care delivery system;
(2) establish an electronic data interchange system that
may be used by the public and private sectors to exchange health
care data in a cost-efficient manner;
(3) develop a mechanism to collect, analyze, and
disseminate information for comparing the cost and quality of
health care delivery system components, including health plan
companies and provider organizations;
(4) develop policies and procedures to protect the privacy
of individual-identifiable data, and to assure appropriate
access to and disclosure of information specific to individual
health plan companies and provider organizations collected
pursuant to this section; and
(5) use and build upon existing data sources and
performance measurement efforts, and improve upon these existing
data sources and measurement efforts through the integration of
data systems and the standardization of concepts, to the
greatest extent possible.
(b) In carrying out its responsibilities, the health data
institute may contract with private sector organizations
currently collecting data on specific health-related areas of
interest to the health data institute, in order to achieve
maximum efficiency and cost-effectiveness. The health data
institute may establish links between the data collected and
maintained by the health data institute and private sector data
through the health data institute's electronic data interchange
system, and may implement methods to streamline data collection
in order to reduce public and private sector administrative
costs. The health data institute may use or establish links
with public sector data, such as that existing for medical
assistance and Medicare, to the extent permitted by state and
federal law. The health data institute may also recommend
methods to streamline public sector data collection in order to
reduce public and private sector administrative costs.
(c) Any contract with a private sector entity must require
the private sector entity to maintain the data collected
according to the applicable data privacy provisions, as provided
in section 62J.452.
Subd. 4. [DATA COLLECTION PLAN.] (a) The health data
institute shall develop a plan that:
(1) identifies the health care data needs of consumers,
group purchasers, providers, and the state regarding the
performance of health care delivery system components including
health plan companies and provider organizations;
(2) specifies data collection objectives, strategies,
priorities, cost estimates, administrative and operational
guidelines, and implementation timelines for the health data
institute; and
(3) identifies the data needed for the health data
institute to carry out the duties assigned in this section. The
plan must take into consideration existing data sources and data
sources that can easily be made uniform for links to other data
sets.
(b) This plan shall be updated on an annual basis.
Subd. 5. [HEALTH CARE ELECTRONIC DATA INTERCHANGE
SYSTEM.] (a) The health data institute shall establish an
electronic data interchange system that electronically
transmits, collects, archives, and provides users of data with
the data necessary for their specific interests, in order to
promote a high quality, cost-effective, consumer-responsive
health care system. This public-private information system
shall be developed to make health care claims processing and
financial settlement transactions more efficient and to provide
an efficient, unobtrusive method for meeting the shared
electronic data interchange needs of consumers, group
purchasers, providers, and the state.
(b) The health data institute shall operate the Minnesota
center for health care electronic data interchange established
in section 62J.57, and shall integrate the goals, objectives,
and activities of the center with those of the health data
institute's electronic data interchange system.
Subd. 6. [PERFORMANCE MEASUREMENT INFORMATION.] (a) The
health data institute shall develop and implement a performance
measurement plan to analyze and disseminate health care data to
address the needs of consumers, group purchasers, providers, and
the state for performance measurement at various levels of the
health care system in the state. The plan shall include a
mechanism to:
(1) provide comparative information to consumers,
purchasers, and policymakers for use in performance assessment
of health care system components, including health plan
companies and provider organizations;
(2) complement and enhance, but not replace, existing
internal performance improvement efforts of health care
providers and plans; and
(3) reduce unnecessary administrative costs in the health
care system by eliminating duplication in the collection of data
for both evaluation and improvement efforts.
(b) Performance measurement at the provider organization
level may be conducted on a condition-specific basis. Criteria
for selecting conditions for measurement may include:
(1) relevance to consumers and purchasers;
(2) prevalence of conditions;
(3) costs related to diagnosis and treatment;
(4) demonstrated efficacy of treatments;
(5) evidence of variability in management;
(6) existence of risk adjustment methodologies to control
for patient and other risk factors contributing to variation in
cost and quality;
(7) existence of practice guidelines related to the
condition; and
(8) relevance of the condition to public health goals.
(c) Performance measurement on a condition-specific basis
may consider multiple dimensions of performance, including, but
not limited to:
(1) accessibility;
(2) appropriateness;
(3) effectiveness, including clinical outcomes, patient
satisfaction, and functional status; and
(4) efficiency.
(d) Collection of data for condition-specific performance
measurement may be conducted at the patient level.
Encounter-level data collected for this purpose may include
unique identifiers for patients, providers, payers, and
employers in order to link episodes of care across care settings
and over time. The health data institute must encrypt patient
identifiers to prevent identification of individual patients and
to enable release of otherwise private data to researchers,
providers, and group purchasers in a manner consistent with
chapter 13 and sections 62J.452 and 144.335.
Subd. 6a. [HEALTH PLAN COMPANY PERFORMANCE
MEASUREMENT.] As part of the performance measurement plan
specified in subdivision 6, the health data institute shall
develop a mechanism to assess the performance of health plan
companies, and to disseminate this information through reports
and other means to consumers, purchasers, policymakers, and
other interested parties, consistent with the data policies
specified in section 62J.452.
Subd. 6b. [CONSUMER SURVEYS.] (a) The health data
institute shall develop and implement a mechanism for collecting
comparative data on consumer perceptions of the health care
system, including consumer satisfaction, through adoption of a
standard consumer survey. This survey shall include enrollees
in community integrated service networks, integrated service
networks, health maintenance organizations, preferred provider
organizations, indemnity insurance plans, public programs, and
other health plan companies. The health data institute, in
consultation with the health care commission, shall determine a
mechanism for the inclusion of the uninsured. This consumer
survey may be conducted every two years. A focused survey may
be conducted on the off years. Health plan companies and group
purchasers shall provide to the health data institute roster
data as defined in subdivision 2, including the names,
addresses, and telephone numbers of enrollees and former
enrollees and other data necessary for the completion of this
survey. This roster data provided by the health plan companies
and group purchasers is classified as provided under section
62J.452. The health data institute may analyze and prepare
findings from the raw, unaggregated data, and the findings from
this survey may be included in the health plan company
performance reports specified in subdivision 6a, and in other
reports developed and disseminated by the health data institute
and the commissioner. The raw, unaggregated data is classified
as provided under section 62J.452, and may be made available by
the health data institute to the extent permitted under section
62J.452. The health data institute shall provide raw,
unaggregated data to the commissioner. The survey may include
information on the following subjects:
(1) enrollees' overall satisfaction with their health care
plan;
(2) consumers' perception of access to emergency, urgent,
routine, and preventive care, including locations, hours,
waiting times, and access to care when needed;
(3) premiums and costs;
(4) technical competence of providers;
(5) communication, courtesy, respect, reassurance, and
support;
(6) choice and continuity of providers;
(7) continuity of care;
(8) outcomes of care;
(9) services offered by the plan, including range of
services, coverage for preventive and routine services, and
coverage for illness and hospitalization;
(10) availability of information; and
(11) paperwork.
(b) The health data institute shall appoint a consumer
advisory group which shall consist of 13 individuals,
representing enrollees from public and private health plan
companies and programs and two uninsured consumers, to advise
the health data institute on issues of concern to consumers.
The advisory group must have at least one member from each
regional coordinating board region of the state. The advisory
group expires June 30, 1996.
Subd. 6c. [PROVIDER ORGANIZATION PERFORMANCE MEASUREMENT.]
As part of the performance measurement plan specified in
subdivision 6, the health data institute shall develop a
mechanism to assess the performance of hospitals and other
provider organizations, and to disseminate this information to
consumers, purchasers, policymakers, and other interested
parties, consistent with the data policies specified in section
62J.452. Data to be collected may include structural
characteristics including staff-mix and nurse-patient ratios.
In selecting additional data for collection, the health data
institute may consider:
(1) feasibility and statistical validity of the indicator;
(2) purchaser and public demand for the indicator;
(3) estimated expense of collecting and reporting the
indicator; and
(4) usefulness of the indicator for internal improvement
purposes.
Subd. 7. [DISSEMINATION OF REPORTS; OTHER
INFORMATION.] (a) The health data institute shall establish a
mechanism for the dissemination of reports and other information
to consumers, group purchasers, health plan companies,
providers, and the state. When applicable, the health data
institute shall coordinate its dissemination of information
responsibilities with those of the commissioner, to the extent
administratively efficient and effective.
(b) The health data institute may require those requesting
data from its databases to contribute toward the cost of data
collection through the payments of fees.
(c) The health data institute shall not allow a group
purchaser or health care provider to use or have access to the
electronic data interchange system or to access data under
section 62J.452, subdivision 6 or 7, unless the group purchaser
or health care provider cooperates with the data collection
efforts of the health data institute by submitting or making
available through the EDI system or other means all data
requested by the health data institute. The health data
institute shall prohibit group purchasers and health care
providers from transferring, providing, or sharing data obtained
from the health data institute under section 62J.452,
subdivision 6 or 7, with a group purchaser or health care
provider that does not cooperate with the data collection
efforts of the health data institute.
Subd. 8. [ANNUAL REPORT.] (a) The health data institute
shall submit to the chairs of the senate joint crime prevention
and judiciary subcommittee on privacy, the house of
representatives judiciary committee, the legislative commission
on health care access, the commissioner, and the governor a
report on the activities of the health data institute by
February 1 of each year beginning February 1, 1996. The report
shall include:
(1) a description of the data initiatives undertaken by the
health data institute, including a statement of the purpose and
a summary of the results of the initiative;
(2) a description of the steps taken by the health data
institute to comply with the confidentiality requirements of
this section and other applicable laws, and of the health data
institute's internal policies and operating procedures relating
to data privacy and confidentiality; and
(3) a description of the actions taken by the health data
institute to ensure that the EDI system being established
pursuant to section 62J.451, subdivision 3, clause (2), and
subdivision 5, protects the confidentiality requirements of this
section and other applicable laws.
(b) If the health data institute amends or adopts an
internal policy or operating procedure relating to data privacy
and confidentiality, it shall submit copies of such policy or
procedure within 30 days of its adoption to the public officials
identified in this subdivision.
Subd. 9. [BOARD OF DIRECTORS.] The health data institute
is governed by a 20-member board of directors consisting of the
following members:
(1) two representatives of hospitals, one appointed by the
Minnesota Hospital Association and one appointed by the
Metropolitan HealthCare Council, to reflect a mix of urban and
rural institutions;
(2) four representatives of health carriers, two appointed
by the Minnesota council of health maintenance organizations,
one appointed by Blue Cross and Blue Shield of Minnesota, and
one appointed by the Insurance Federation of Minnesota;
(3) two consumer members, one appointed by the
commissioner, and one appointed by the AFL-CIO as a labor union
representative;
(4) five group purchaser representatives appointed by the
Minnesota consortium of health care purchasers to reflect a mix
of urban and rural, large and small, and self-insured
purchasers;
(5) two physicians appointed by the Minnesota Medical
Association, to reflect a mix of urban and rural practitioners;
(6) one representative of teaching and research
institutions, appointed jointly by the Mayo Foundation and the
Minnesota Association of Public Teaching Hospitals;
(7) one nursing representative appointed by the Minnesota
Nurses Association; and
(8) three representatives of state agencies, one member
representing the department of employee relations, one member
representing the department of human services, and one member
representing the department of health.
Subd. 10. [TERMS; COMPENSATION; REMOVAL; AND
VACANCIES.] The board is governed by section 15.0575.
Subd. 11. [STATUTORY GOVERNANCE.] The health data
institute is subject to chapter 13 and section 471.705 but is
not otherwise subject to laws governing state agencies except as
specifically provided in this chapter.
Subd. 12. [STAFF.] The board may hire an executive
director. The executive director and other health data
institute staff are not state employees but are covered by
section 3.736. The executive director and other health data
institute staff may participate in the following plans for
employees in the unclassified service until January 1, 1996:
the state retirement plan, the state deferred compensation plan,
and the health, dental, and life insurance plans. The attorney
general shall provide legal services to the board.
Subd. 13. [FEDERAL AND OTHER GRANTS.] The health data
institute may seek federal funding, and funding from private and
other nonstate sources for the initiative required by the board.
Subd. 14. [CONTRACTS.] To carry out the duties assigned in
this section, the health data institute may contract with
private sector entities. Any contract must require the private
sector entity to maintain the data which it receives according
to the statutory provisions applicable to the data and any other
applicable provision specified in section 62J.452.
Subd. 15. [NONLIMITING.] Nothing in this section shall be
construed to limit the powers granted to the commissioner of
health in chapter 62D, 62N, 144, or 144A.
Subd. 16. [CLARIFICATION OF INTENT.] This section is
intended to provide the health data institute with primary
responsibility for establishing a data collection plan,
establishing an electronic data interchange system, measuring
performance at the provider organization and health plan company
levels, collecting condition-specific data, developing and
administering consumer surveys, and performing other duties
specifically assigned in this section. The commissioner of
health may perform these duties only if the commissioner
determines that these duties will not be performed by the health
data institute.
Sec. 16. [62J.452] [PROTECTION OF PRIVACY AND
CONFIDENTIALITY OF HEALTH CARE DATA.]
Subdivision 1. [STATEMENT OF PURPOSE.] The health data
institute shall adopt data collection, analysis, and
dissemination policies that reflect the importance of protecting
the right of privacy of patients in their health care data in
connection with each data initiative that the health data
institute intends to undertake.
Subd. 2. [DATA CLASSIFICATIONS.] (a) Data collected,
obtained, received, or created by the health data institute
shall be private or nonpublic, as applicable, unless given a
different classification in this subdivision. Data classified
as private or nonpublic under this subdivision may be released
or disclosed only as permitted under this subdivision and under
the other subdivisions referenced in this subdivision. For
purposes of this section, data that identify individual patients
or industry participants are private data on individuals or
nonpublic data, as appropriate. Data not on individuals are
nonpublic data. Notwithstanding sections 13.03, subdivisions 6
to 8; 13.10, subdivisions 1 to 4; and 138.17, data received by
the health data institute shall retain the classification
designated under this chapter and shall not be disclosed other
than pursuant to this chapter. Nothing in this subdivision
prevents patients from gaining access to their health record
information pursuant to section 144.335.
(b) When industry participants, as defined in section
62J.451, are required by statute to provide, either directly or
through a contractor, as defined in section 62J.451, subdivision
2, paragraph (c), patient identifying data to the commissioner
pursuant to this chapter or to the health data institute
pursuant to section 62J.451, the industry participant or its
contractor shall be able to provide the data with or without
patient consent, and may not be held liable for doing so.
(c) When an industry participant submits patient
identifying data to the health data institute, and the data is
submitted to the health data institute in electronic form, or
through other electronic means including, but not limited to,
the electronic data interchange system defined in section
62J.451, the industry participant shall submit the patient
identifying data in encrypted form, using an encryption method
supplied or specified by the health data institute. Submission
of encrypted data as provided in this paragraph satisfies the
requirements of section 144.335, subdivision 3b.
(d) Patient identifying data may be disclosed only as
permitted under subdivision 3.
(e) Industry participant identifying data which is not
patient identifying data may be disclosed only by being made
public in an analysis as permitted under subdivisions 4 and 5 or
through access to an approved researcher, industry participant,
or contractor as permitted under subdivision 6 or 7.
(f) Data that is not patient identifying data and not
industry participant identifying data is public data.
(g) Data that describes the finances, governance, internal
operations, policies, or operating procedures of the health data
institute, and that does not identify patients or industry
participants or identifies them only in connection with their
involvement with the health data institute, is public data.
Subd. 3. [PATIENT IDENTIFYING DATA.] (a) The health data
institute must not make public any analysis that contains
patient identifying data.
(b) The health data institute may disclose patient
identifying data only as follows:
(1) to research organizations that meet the requirements
set forth in subdivision 6, paragraph (a), but only to the
extent that such disclosure is also permitted by section
144.335, subdivision 3a, paragraph (a); or
(2) to a contractor of, or vendor of services to the health
data institute for the purposes of conducting a survey or
analysis, provided that such contractor or vendor agrees to
comply with all data privacy requirements applicable to the
health data institute, and to destroy or return to the health
data institute all copies of patient identifying data in the
possession of such contractor or vendor upon completion of the
contract.
Subd. 4. [ANALYSIS TO BE MADE PUBLIC BY THE HEALTH DATA
INSTITUTE.] (a) Notwithstanding the classification under
subdivision 2 or other provision of state law of data included
or used in an analysis, the health data institute may make
public data in an analysis pursuant to this subdivision and
subdivision 5. Such analysis may include industry participant
identifying data but must not include patient identifying data.
In making its determination as to whether to make an analysis or
the data used in the analysis public, the health data institute
shall consider and determine, in accordance with policies and
criteria developed by the health data institute, that the data
and analysis are sufficiently accurate, complete, reliable,
valid, and as appropriate, case-mixed and severity adjusted, and
statistically and clinically significant.
(b) Prior to making an analysis public, the health data
institute must provide to any industry participant identified in
the analysis an opportunity to use the fair hearing procedure
established under subdivision 5.
(c) Accompanying an analysis made public by the health data
institute, the health data institute shall also make public
descriptions of the database used in the analysis, the methods
of adjusting for case mix and severity, and assuring accuracy,
completeness, reliability, and statistical and clinical
significance, as appropriate, and appropriate uses of the
analysis and related analytical data, including precautionary
statements regarding the limitations of the analysis and related
analytical data.
Subd. 5. [FAIR HEARING PROCEDURE PRIOR TO MAKING AN
ANALYSIS PUBLIC.] (a) The health data institute may not make
public an analysis that identifies an industry participant
unless the health data institute first complies with this
subdivision. A draft of the portion of the analysis that
identifies an industry participant must be furnished upon an
industry participant's request to that industry participant
prior to making that portion of the analysis public. Such draft
analysis is private or nonpublic, as applicable. The industry
participants so identified have the right to a hearing, at which
the industry participants or their contractors, as defined in
section 62J.451, subdivision 2, paragraph (c), may object to or
seek modification of the analysis. The cost of the hearing
shall be borne by the industry participant requesting the
hearing.
(b) The health data institute shall establish the hearing
procedure in writing. The hearing procedure shall include the
following:
(1) the provision of reasonable notice of the health data
institute's intention to make such analysis public;
(2) an opportunity for the identified industry participants
to submit written statements to the health data institute board
of directors or its designate, to be represented by a
contractor, as defined in section 62J.451, subdivision 2,
paragraph (c), or other individual or entity acting on behalf of
and chosen by the industry participant for this purpose, and to
append a statement to such analysis to be included with it when
and if the analysis is made public; and
(3) access by the identified industry participants to
industry participant identifying data, but only as permitted by
subdivision 6 or 7.
(c) The health data institute shall make the hearing
procedure available in advance to industry participants which
are identified in an analysis. The written hearing procedure is
public data. The following data related to a hearing is public:
(1) the parties involved;
(2) the dates of the hearing; and
(3) a general description of the issue and the results of
the hearing; all other data relating to the hearing is private
or nonpublic.
Subd. 6. [ACCESS BY APPROVED RESEARCHERS TO DATA THAT
IDENTIFIES INDUSTRY PARTICIPANTS BUT DOES NOT IDENTIFY
PATIENTS.] (a) The health data institute shall provide access to
industry participant identifying data, but not patient
identifying data, once those data are in analyzable form, upon
request to research organizations or individuals that:
(1) have as explicit goals research purposes that promote
individual or public health and the release of research results
to the public as determined by the health data institute
according to standards it adopts for evaluating such goals;
(2) enforce strict and explicit policies which protect the
confidentiality and integrity of data as determined by the
health data institute according to standards it adopts for
evaluating such policies;
(3) agree not to make public, redisclose, or transfer the
data to any other individual or organization, except as
permitted under paragraph (b);
(4) demonstrate a research purpose for the data that can be
accomplished only if the data are provided in a form that
identifies specific industry participants as determined by the
health data institute according to standards it adopts for
evaluating such research purposes; and
(5) agree to disclose analysis in a public forum or
publication only pursuant to subdivisions 4 and 5 and other
applicable statutes and the health data institute's operating
rules governing the making of an analysis public by the health
data institute.
(b) Contractors of entities that have access under
paragraph (a) may also have access to industry participant
identifying data, provided that the contract requires the
contractor to comply with the confidentiality requirements set
forth in this section and under any other statute applicable to
the entity.
Subd. 7. [ACCESS BY INDUSTRY PARTICIPANTS TO DATA THAT
IDENTIFIES INDUSTRY PARTICIPANTS BUT DOES NOT IDENTIFY
PATIENTS.] (a) The health data institute may provide, to an
industry participant, data that identifies that industry
participant or other industry participants, to the extent
permitted under this subdivision. An employer or an employer
purchasing group may receive data relating to care provided to
patients for which that employer acts as the payer. A health
plan company may receive data relating to care provided to
enrollees of that health plan company. A provider may receive
data relating to care provided to patients of that provider.
(b) An industry participant may receive data that
identifies that industry participant or other industry
participants and that relates to care purchased or provided by
industry participants other than the industry participant
seeking the data. These data must be provided by the health
data institute only with appropriate authorization from all
industry participants identified.
(c) The health data institute must not provide access to
any data under this subdivision that is patient identifying data
as defined in section 62J.451, subdivision 2, paragraph (m),
even if providing that data would otherwise be allowed under
this subdivision.
(d) To receive data under this subdivision, an industry
participant must cooperate with the health data institute as
provided under section 62J.451, subdivision 7, paragraph (c).
(e) Contractors of entities that have access under
paragraph (b) may have access to industry participant
identifying data, provided that the contract requires the
contractor to comply with the confidentiality requirements set
forth in this section and under any other statute applicable to
the entity.
Subd. 8. [STATUS OF DATA ON THE ELECTRONIC DATA
INTERCHANGE SYSTEM.] (a) Data created or generated by or in the
custody of an industry participant, and transferred
electronically by that industry participant to another industry
participant using the EDI system developed, implemented,
maintained, or operated by the health data institute, as
permitted by section 62J.451, subdivision 3, clause (2), and
subdivision 5, is not subject to this section or to chapter 13
except as provided below.
(b) Data created or generated by or in the custody of an
industry participant is subject to the privacy protections
applicable to the data, including, but not limited to, chapter
13 with respect to state agencies and political subdivisions,
the Minnesota insurance fair information reporting act with
respect to industry participants subject to it, and section
144.335, with respect to providers and other industry
participants subject to such section.
Subd. 9. [AUTHORIZATION OF STATE AGENCIES AND POLITICAL
SUBDIVISIONS TO PROVIDE DATA.] (a) Notwithstanding any
limitation in chapter 13 or section 62J.321, subdivision 5,
regarding the disclosure of not public data, all state agencies
and political subdivisions, including, but not limited to,
municipalities, counties, and hospital districts may provide not
public data relating to health care costs, quality, or outcomes
to the health data institute for the purposes set forth in
section 62J.451.
(b) Data provided by the commissioner pursuant to paragraph
(a) of this subdivision may not include patient identifying data
as defined in section 62J.451, subdivision 2, paragraph (m).
For data provided by the commissioner of health pursuant to
paragraph (a), the health data institute and anyone receiving
the data from the health data institute, is prohibited from
unencrypting or attempting to link the data with other patient
identifying data sources.
(c) Any data provided to the health data institute pursuant
to paragraph (a) shall retain the same classification that it
had with the state agency or political subdivision that provided
it. The authorization in this subdivision is subject to any
federal law restricting or prohibiting such disclosure of the
data described above.
(d) Notwithstanding any limitation in chapter 13 or
sections 62J.451 and 62J.452 regarding the disclosure of
nonpublic and private data, the health data institute may
provide nonpublic and private data to any state agency that is a
member of the board of the health data institute. Any such data
provided to a state agency shall retain nonpublic or private
classification, as applicable.
Subd. 10. [CIVIL REMEDIES.] Violation of any of the
confidentiality requirements set forth in subdivision 3; 4,
paragraph (a); 6; or 7, by the health data institute, its board
members, employees and contractors, any industry participant, or
by any other person shall be subject to section 13.08,
including, but not limited to, the immunities set forth in
section 13.08, subdivisions 5 and 6. The health data institute
shall not be liable for exercising its discretion in a manner
that is not an abuse of discretion with respect to matters under
its discretion by this section or section 62J.451. The health
data institute shall not be liable for the actions of persons
not under the direction and control of the health data
institute, where it has performed its responsibilities to
protect data privacy by complying with the requirements of this
section and other applicable laws with regard to the disclosure
of data. The remedies set forth in this section do not preclude
any person from pursuing any other remedies authorized by law.
Subd. 11. [PENALTIES.] (a) Any person who willfully
violates the confidentiality requirements set forth in
subdivision 3; 4, paragraph (a); 6; or 7, shall be guilty of a
misdemeanor.
(b) Any person who willfully violates the confidentiality
requirements of subdivision 3, 4, 6, 7, 8, or 9, by willfully
disclosing patient or industry participant identifying data for
compensation or remuneration of any kind or for the purpose of
damaging the reputation of any patient or industry participant
or any other malicious purpose, shall be guilty of a gross
misdemeanor.
Subd. 12. [DISCOVERABILITY OF HEALTH DATA INSTITUTE
DATA.] (a) Data created, collected, received, maintained, or
disseminated by the health data institute shall not be subject
to discovery or introduction into evidence in any civil or
criminal action. Data created, collected, received, maintained,
or disseminated by the health data institute that is otherwise
available from original sources is subject to discovery from
those sources and may be introduced into evidence in civil or
criminal actions in accordance with and subject to applicable
laws and rules of evidence and civil or criminal procedure, as
applicable.
(b) Information related to submission of data to the health
data institute by industry participants or contractors of
industry participants is not discoverable from the health data
institute, the industry participants, the contractors, or any
other person or entity, in any civil or criminal action.
Discovery requests prohibited under this paragraph include, but
are not limited to, document requests or interrogatories that
ask for "all data provided to the Minnesota health data
institute."
Sec. 17. Minnesota Statutes 1994, section 62J.54, is
amended to read:
62J.54 [IDENTIFICATION AND IMPLEMENTATION OF UNIQUE
IDENTIFIERS.]
Subdivision 1. [UNIQUE IDENTIFICATION NUMBER FOR HEALTH
CARE PROVIDER ORGANIZATIONS.] (a) On and after January 1,
1996 1998, all group purchasers and health care providers in
Minnesota shall use a unique identification number to identify
health care provider organizations, except as provided in
paragraph (d).
(b) Following the recommendation of the workgroup for
electronic data interchange, the federal tax identification
number assigned to each health care provider organization by the
Internal Revenue Service of the Department of the Treasury shall
be used as the unique identification number for health care
provider organizations.
(c) The unique health care provider organization identifier
shall be used for purposes of submitting and receiving claims,
and in conjunction with other data collection and reporting
functions.
(d) The state and federal health care programs administered
by the department of human services shall use the unique
identification number assigned to health care providers for
implementation of the Medicaid Management Information System or
the uniform provider identification number (UPIN) assigned by
the Health Care Financing Administration.
Subd. 2. [UNIQUE IDENTIFICATION NUMBER FOR INDIVIDUAL
HEALTH CARE PROVIDERS.] (a) On and after January 1, 1996 1998,
all group purchasers and health care providers in Minnesota
shall use a unique identification number to identify an
individual health care provider, except as provided in paragraph
(d).
(b) The uniform provider identification number (UPIN)
assigned by the Health Care Financing Administration shall be
used as the unique identification number for individual health
care providers. Providers who do not currently have a UPIN
number shall request one from the health care financing
administration.
(c) The unique individual health care provider identifier
shall be used for purposes of submitting and receiving claims,
and in conjunction with other data collection and reporting
functions.
(d) The state and federal health care programs administered
by the department of human services shall use the unique
identification number assigned to health care providers for
implementation of the Medicaid Management Information System or
the uniform provider identification number (UPIN) assigned by
the health care financing administration.
Subd. 3. [UNIQUE IDENTIFICATION NUMBER FOR GROUP
PURCHASERS.] (a) On and after January 1, 1996 1998, all group
purchasers and health care providers in Minnesota shall use a
unique identification number to identify group purchasers.
(b) The federal tax identification number assigned to each
group purchaser by the Internal Revenue Service of the
Department of the Treasury shall be used as the unique
identification number for group purchasers. This paragraph
applies until the codes described in paragraph (c) are available
and feasible to use, as determined by the commissioner.
(c) A two-part code, consisting of 11 characters and
modeled after the National Association of Insurance
Commissioners company code shall be assigned to each group
purchaser and used as the unique identification number for group
purchasers. The first six characters, or prefix, shall contain
the numeric code, or company code, assigned by the National
Association of Insurance Commissioners. The last five
characters, or suffix, which is optional, shall contain further
codes that will enable group purchasers to further route
electronic transaction in their internal systems.
(d) The unique group purchaser identifier shall be used for
purposes of submitting and receiving claims, and in conjunction
with other data collection and reporting functions.
Subd. 4. [UNIQUE PATIENT IDENTIFICATION NUMBER.] (a) On
and after January 1, 1996 1998, all group purchasers and health
care providers in Minnesota shall use a unique identification
number to identify each patient who receives health care
services in Minnesota, except as provided in paragraph (e).
(b) Except as provided in paragraph (d), following the
recommendation of the workgroup for electronic data interchange,
the social security number of the patient shall be used as the
unique patient identification number.
(c) The unique patient identification number shall be used
by group purchasers and health care providers for purposes of
submitting and receiving claims, and in conjunction with other
data collection and reporting functions.
(d) The commissioner shall develop an alternate numbering
system for patients who do not have or refuse to provide a
social security number. This provision does not require that
patients provide their social security numbers and does not
require group purchasers or providers to demand that patients
provide their social security numbers. Group purchasers and
health care providers shall establish procedures to notify
patients that they can elect not to have their social security
number used as the unique patient identification number.
(e) The state and federal health care programs administered
by the department of human services shall use the unique person
master index (PMI) identification number assigned to clients
participating in programs administered by the department of
human services.
Sec. 18. Minnesota Statutes 1994, section 62J.55, is
amended to read:
62J.55 [PRIVACY OF UNIQUE IDENTIFIERS.]
(a) When the unique identifiers specified in section 62J.54
are used for data collection purposes, the identifiers must be
encrypted, as required in section 62J.30 62J.321, subdivision 6
1. Encryption must follow encryption standards set by the
National Bureau of Standards and approved by the American
National Standards Institute as ANSIX3. 92-1982/R 1987 to
protect the confidentiality of the data. Social security
numbers must not be maintained in unencrypted form in the
database, and the data must never be released in a form that
would allow for the identification of individuals. The
encryption algorithm and hardware used must not use clipper chip
technology.
(b) Providers and group purchasers shall treat medical
records, including the social security number if it is used as a
unique patient identifier, in accordance with section 144.335.
The social security number may be disclosed by providers and
group purchasers to the commissioner as necessary to allow
performance of those duties set forth in section 144.05.
Sec. 19. Minnesota Statutes 1994, section 62J.58, is
amended to read:
62J.58 [IMPLEMENTATION OF STANDARD TRANSACTION SETS.]
Subdivision 1. [CLAIMS PAYMENT.] (a) By July 1, 1995 Six
months from the date the commissioner formally recommends the
use of guides to implement core transaction sets pursuant to
section 62J.56, subdivision 3, all category I industry
participants, except pharmacists, shall be able to submit or
accept, as appropriate, the ANSI ASC X12 835 health care claim
payment/advice transaction set (draft standard for trial use
version 3030) for electronic transfer of payment information.
(b) By July 1, 1996, and all category II industry
participants, except pharmacists, shall be able to submit or
accept, as appropriate, the ANSI ASC X12 835 health care claim
payment/advice transaction set (draft standard for trial use
version 3030) for electronic submission of payment information
to health care providers.
Subd. 2. [CLAIMS SUBMISSION.] Beginning July 1, 1995 Six
months from the date the commissioner formally recommends the
use of guides to implement core transaction sets pursuant to
section 62J.56, subdivision 3, all category I and category II
industry participants, except pharmacists, shall be able to
accept or submit, as appropriate, the ANSI ASC X12 837 health
care claim transaction set (draft standard for trial use version
3030) for the electronic transfer of health care claim
information. Category II industry participants, except
pharmacists, shall be able to accept or submit, as appropriate,
this transaction set, beginning July 1, 1996.
Subd. 3. [ENROLLMENT INFORMATION.] Beginning January 1,
1996 Six months from the date the commissioner formally
recommends the use of guides to implement core transaction sets
pursuant to section 62J.56, subdivision 3, all category I and
category II industry participants, excluding pharmacists, shall
be able to accept or submit, as appropriate, the ANSI ASC X12
834 health care enrollment transaction set (draft standard for
trial use version 3030) for the electronic transfer of
enrollment and health benefit information. Category II industry
participants, except pharmacists, shall be able to accept or
submit, as appropriate, this transaction set, beginning January
1, 1997.
Subd. 4. [ELIGIBILITY INFORMATION.] By January 1, 1996 Six
months from the date the commissioner formally recommends the
use of guides to implement core transaction sets pursuant to
section 62J.56, subdivision 3, all category I and category II
industry participants, except pharmacists, shall be able to
accept or submit, as appropriate, the ANSI ASC X12 270/271
health care eligibility transaction set (draft standard for
trial use version 3030) for the electronic transfer of health
benefit eligibility information. Category II industry
participants, except pharmacists, shall be able to accept or
submit, as appropriate, this transaction set, beginning January
1, 1997.
Subd. 5. [APPLICABILITY.] This section does not require a
group purchaser, health care provider, or employer to use
electronic data interchange or to have the capability to do so.
This section applies only to the extent that a group purchaser,
health care provider, or employer chooses to use electronic data
interchange.
Sec. 20. Minnesota Statutes 1994, section 214.16,
subdivision 2, is amended to read:
Subd. 2. [BOARD COOPERATION REQUIRED.] The board shall
assist the commissioner of health and the data analysis unit in
data collection activities required under Laws 1992, chapter
549, article 7, and shall assist the commissioner of revenue in
activities related to collection of the health care provider tax
required under Laws 1992, chapter 549, article 9. Upon the
request of the commissioner, the data analysis unit, or the
commissioner of revenue, the board shall make available names
and addresses of current licensees and provide other information
or assistance as needed.
Sec. 21. Minnesota Statutes 1994, section 214.16,
subdivision 3, is amended to read:
Subd. 3. [GROUNDS FOR DISCIPLINARY ACTION.] The board
shall take disciplinary action, which may include license
revocation, against a regulated person for:
(1) intentional failure to provide the commissioner of
health or the data analysis unit established under section
62J.30 with the data required under chapter 62J;
(2) intentional failure to provide the commissioner of
revenue with data on gross revenue and other information
required for the commissioner to implement sections 295.50 to
295.58; and
(3) intentional failure to pay the health care provider tax
required under section 295.52.
Sec. 22. [RULES.]
Notwithstanding Minnesota Statutes, section 14.05,
subdivision 1, Minnesota Rules, chapters 4650, 4651, and 4652,
shall continue in effect under the authority granted in
Minnesota Statutes, section 62J.321, subdivision 6.
Sec. 23. [INSTRUCTION TO REVISOR.]
(a) The revisor of statutes is instructed to change the
term "data institute" or "institute", where applicable, to
"health data institute" in the 1996 edition of Minnesota
Statutes and Minnesota Rules.
(b) The revisor of statutes is instructed to change any
statutory reference to the information clearinghouse from
Minnesota Statutes, section 62J.33 or 62J.33, subdivision 2, to
62J.2930, in the 1996 edition of Minnesota Statutes and
Minnesota Rules.
Sec. 24. [REPEALER.]
Minnesota Statutes 1994, sections 62J.30; 62J.31; 62J.32;
62J.33; 62J.34; 62J.35; 62J.41, subdivisions 3 and 4; 62J.44;
and 62J.45, are repealed.
ARTICLE 6
MINNESOTACARE PROGRAM, PRESCRIPTION DRUG COVERAGE,
AND THE HEALTH CARE REFORM WAIVER
Section 1. [62J.66] [DEFINITIONS.]
Subdivision 1. [APPLICABILITY.] For purposes of section
62J.66 and 62J.68, the following definitions apply.
Subd. 2. [DISCOUNTED PRICE.] The "discounted price" means
the lesser of the average wholesale price for a prescription
drug minus 20 percent or the usual and customary retail price,
including any dispensing fee, minus five percent.
Subd. 3. [ELIGIBLE SENIOR.] "Eligible senior" means a
senior citizen eligible for the senior drug discount program
under section 62J.68, subdivision 3.
Subd. 4. [SENIOR CITIZEN.] "Senior citizen" means a
resident of Minnesota who is age 65 or older.
Subd. 5. [SENIOR DRUG DISCOUNT PROGRAM.] "Senior drug
discount program" means the program established in section
62J.68.
Subd. 6. [PARTICIPATING DRUG MANUFACTURER.] "Participating
drug manufacturer" means any manufacturer who agrees to
voluntarily participate in the senior drug discount program.
Subd. 7. [PARTICIPATING CLAIMS PROCESSING
COMPANIES.] "Participating claims processing companies" means
entities, including, but not limited to, pharmacy benefit
management companies, that are awarded a contract by the
department of administration to provide on-line services to
process payments to participating pharmacies.
Subd. 8. [AVERAGE MANUFACTURER PRICE.] "Average
manufacturer price" has the meaning assigned to the term by the
Secretary of Health and Human Services for purposes of the
federal drug rebate program established under the Omnibus Budget
Reconciliation Act of 1990 and section 1927 of the Social
Security Act.
Sec. 2. [62J.68] [SENIOR DRUG DISCOUNT PROGRAM.]
Subdivision 1. [ESTABLISHMENT AND ADMINISTRATION.] (a) The
commissioner of administration shall award a contract or
contracts to claims processing companies to process payments to
participating pharmacies. The contract must include:
(1) provisions for participating manufacturers to provide
discount payments, through participating claims processing
companies, equal to four percent of the average manufacturer
price; and
(2) quality assurance and verification procedures and
authority to conduct audits of pharmacy claims as necessary to
ensure that pharmacy reimbursement payments are appropriate and
justified.
(b) The commissioner of administration may establish an
expert panel to assist in the development of the request for
proposal for awarding the contract or contracts to process
payments for the senior drug discount program.
Subd. 2. [PARTICIPATING MANUFACTURERS.] Participating
manufacturers agree to:
(1) pay participating pharmacies through the claims
processor an amount equal to four percent of the average
manufacturer price;
(2) process discount payments through participating claims
processing companies according to the timelines used under the
medical assistance program;
(3) pay administrative fees established under subdivision 7.
Subd. 3. [PARTICIPATING PHARMACIES.] Participating
pharmacies agree to:
(1) provide eligible seniors the discounted price
established by the senior drug discount program;
(2) accept payments from participating claims processing
companies equal to four percent of the average manufacturer
price; and
(3) not charge eligible seniors a dispensing fee greater
than $3.
Subd. 4. [ENROLLMENT.] The commissioner of human services
shall determine eligibility as specified in subdivision 5 and
enroll senior citizens in the senior drug discount program. The
commissioner may use volunteers to assist in eligibility and
enrollment duties. The commissioner of human services shall
post the eligibility of the enrollees to the Medicaid Management
Information System (MMIS) where it can be assessed by
participating pharmacies through the department's eligibility
verification system and point-of-sale system upon presentation
of the enrollee's Minnesota health care programs card.
Subd. 5. [ELIGIBILITY.] (a) Senior citizens are eligible
for the program if:
(1) their household income does not exceed 200 percent of
the federal poverty guidelines;
(2) they are enrolled in Medicare Part A and Part B;
(3) they do not have coverage for prescription drugs under
a health plan, as defined in section 62Q.01, subdivision 3;
(4) they do not have coverage for prescription drugs under
a Medicare supplement plan, as defined in sections 62A.31 to
62A.44, or policies, contracts, or certificates that supplement
Medicare issued by health maintenance organizations or those
policies, contracts, or certificates governed by section 1833 or
1976 of the federal Social Social Security Act, United States
Code, title 42, section 1395, et seq., as amended, or coverage
for prescription drugs under medical assistance under chapter
256B, general assistance medical care under chapter 256D,
MinnesotaCare, or the qualified medical beneficiaries program;
(5) they meet the residency requirements established under
section 256.9359; and
(6) they do not have coverage for prescription drugs under
medical assistance, general assistance medical care,
MinnesotaCare, or the qualified Medicare beneficiary program.
(b) The commissioner of human services shall provide each
eligible senior with a Minnesota health care programs card
indicating enrollment in the senior drug discount program.
Eligible seniors must present this card to the participating
pharmacy in order to receive the discounted price.
Subd. 6. [ENROLLMENT FEE.] The commissioner of human
services may establish an annual enrollment fee of $5 for
purposes of administering the senior drug discount program. The
fees shall be deposited in a special revenue account for the
purpose of administration of enrollment to the senior drug
discount program. This account shall be exempt from paying
statewide and agency indirect costs as required under section
16A.127.
Subd. 7. [ADMINISTRATIVE FEE.] The commissioner of
administration may authorize a claims processing contractor to
charge a fixed claims processing fee not to exceed ten cents for
each prescription drug provided to participating seniors under
this section. In the event the commissioner authorizes a claims
processing fee, one-half of the fee must be paid by the
participating manufacturer and one-half by the participating
pharmacy.
Subd. 8. [DISEASE MANAGEMENT FOR DRUG THERAPY.] The
commissioner of human services may establish a disease
management program for drug therapy for eligible senior
citizens. The commissioner may seek grants and donations from
drug manufacturers, drug wholesalers, and other nonstate
entities to establish and administer this disease management
program.
Subd. 9. [SENIOR DRUG DISCOUNT PROGRAM EVALUATION.] The
commissioners of human services and health, in consultation with
the commissioner of administration, shall study the efficiency
and effectiveness of the senior drug discount program. The
commissioners shall examine methods of encouraging participation
by drug manufacturers and pharmacies in the program and any
program modifications necessary to effectively serve eligible
senior citizens. The commissioners shall present a progress
report on the program to the legislature by January 15, 1996,
and recommendations for program changes to the legislature by
January 15, 1997.
Sec. 3. Minnesota Statutes 1994, section 256.9352,
subdivision 3, is amended to read:
Subd. 3. [FINANCIAL MANAGEMENT.] (a) The commissioner
shall manage spending for the MinnesotaCare program in a manner
that maintains a minimum reserve equal to five percent of the
expected cost of state premium subsidies. The commissioner must
make a quarterly assessment of the expected expenditures for the
covered services for the remainder of the current fiscal
year biennium and for the following two fiscal years biennium.
The estimated expenditure, including minimum reserve
requirements, shall be compared to an estimate of the revenues
that will be deposited in the health care access fund. Based on
this comparison, and after consulting with the chairs of the
house ways and means committee and the senate finance committee,
and the legislative commission on health care access, the
commissioner shall make adjustments, as necessary, make the
adjustments specified in paragraph (b) to ensure that
expenditures remain within the limits of available revenues for
the remainder of the current biennium and for the following
biennium. The commissioner shall not hire additional staff
using appropriations from the health care access fund until the
commissioner of finance makes a determination that the
adjustments implemented under paragraph (b) are sufficient to
allow MinnesotaCare expenditures to remain within the limits of
available revenues for the remainder of the current biennium and
for the following biennium.
(b) The adjustments the commissioner may shall use must be
implemented in this order: first, stop enrollment of single
adults and households without children; second, upon 45 days'
notice, stop coverage of single adults and households without
children already enrolled in the MinnesotaCare program; third,
upon 90 days' notice, decrease the premium subsidy amounts by
ten percent for families with gross annual income above 200
percent of the federal poverty guidelines; fourth, upon 90 days'
notice, decrease the premium subsidy amounts by ten percent for
families with gross annual income at or below 200 percent; and
fifth, require applicants to be uninsured for at least six
months prior to eligibility in the MinnesotaCare program. If
these measures are insufficient to limit the expenditures to the
estimated amount of revenue, the commissioner may shall further
limit enrollment or decrease premium subsidies.
The reserve referred to in this subdivision is appropriated
to the commissioner but may only be used upon approval of the
commissioner of finance, if estimated costs will exceed the
forecasted amount of available revenues after all adjustments
authorized under this subdivision have been made.
By February 1, 1995, the department of human services and
the department of health shall develop a plan to adjust benefit
levels, eligibility guidelines, or other steps necessary to
ensure that expenditures for the MinnesotaCare program are
contained within the two percent taxes imposed under section
295.52 and the gross premiums tax imposed under section 60A.15,
subdivision 1, paragraph (e), for fiscal year 1997.
(b) (c) Notwithstanding paragraph (a) paragraphs (a) and
(b), the commissioner shall proceed with the enrollment of
single adults and households without children in accordance with
section 256.9354, subdivision 5, paragraph (a), even if the
expenditures do not remain within the limits of available
revenues through fiscal year 1997 to allow the departments of
human services and health to develop the plan required under
paragraph (a) (b).
Sec. 4. Minnesota Statutes 1994, section 256.9353,
subdivision 1, is amended to read:
Subdivision 1. [COVERED HEALTH SERVICES.] "Covered health
services" means the health services reimbursed under chapter
256B, with the exception of inpatient hospital services, special
education services, private duty nursing services, adult dental
care services other than preventive services, orthodontic
services, nonemergency medical transportation services, personal
care assistant and case management services, hospice care
services, nursing home or intermediate care facilities services,
inpatient mental health services, and chemical dependency
services. Outpatient mental health services covered under the
MinnesotaCare program are limited to diagnostic assessments,
psychological testing, explanation of findings, medication
management by a physician, day treatment, partial
hospitalization, and individual, family, and group psychotherapy.
No public funds shall be used for coverage of abortion
under MinnesotaCare except where the life of the female would be
endangered or substantial and irreversible impairment of a major
bodily function would result if the fetus were carried to term;
or where the pregnancy is the result of rape or incest.
Covered health services shall be expanded as provided in
this section.
Sec. 5. Minnesota Statutes 1994, section 256.9353,
subdivision 3, is amended to read:
Subd. 3. [INPATIENT HOSPITAL SERVICES.] (a) Beginning July
1, 1993, covered health services shall include inpatient
hospital services, including inpatient hospital mental health
services and inpatient hospital and residential chemical
dependency treatment, subject to those limitations necessary to
coordinate the provision of these services with eligibility
under the medical assistance spenddown. The inpatient hospital
benefit for adult enrollees is subject to an annual benefit
limit of $10,000. The commissioner shall provide enrollees with
at least 60 days' notice of coverage for inpatient hospital
services and any premium increase associated with the inclusion
of this benefit.
(b) Enrollees determined by the commissioner to have a
basis of eligibility for medical assistance shall apply for and
cooperate with the requirements of medical assistance by the
last day of the third month following admission to an inpatient
hospital. If an enrollee fails to apply for medical assistance
within this time period, the enrollee and the enrollee's family
shall be disenrolled from the plan within one calendar month and
they may not reenroll until 12 calendar months have elapsed.
Enrollees and enrollees' families disenrolled for not applying
for or not cooperating with medical assistance may not reenroll.
(c) Admissions for inpatient hospital services paid for
under section 256.9362, subdivision 3, must be certified as
medically necessary in accordance with Minnesota Rules, parts
9505.0500 to 9505.0540, except as provided in clauses (1) and
(2):
(1) all admissions must be certified, except those
authorized under rules established under section 254A.03,
subdivision 3, or approved under Medicare; and
(2) payment under section 256.9362, subdivision 3, shall be
reduced by five percent for admissions for which certification
is requested more than 30 days after the day of admission. The
hospital may not seek payment from the enrollee for the amount
of the payment reduction under this clause.
(d) Any enrollee or family member of an enrollee who has
previously been permanently disenrolled from MinnesotaCare for
not applying for and cooperating with medical assistance shall
be eligible to reenroll if 12 calendar months have elapsed since
the date of disenrollment.
Sec. 6. Minnesota Statutes 1994, section 256.9354,
subdivision 1, is amended to read:
Subdivision 1. [CHILDREN; EXPANSION AND CONTINUATION OF
ELIGIBILITY.] (a) [CHILDREN.] Prior to October 1,
1992, "eligible persons" means children who are one year of age
or older but less than 18 years of age who have gross family
incomes that are equal to or less than 150 185 percent of the
federal poverty guidelines and who are not eligible for medical
assistance without a spenddown under chapter 256B and who are
not otherwise insured for the covered services. The period of
eligibility extends from the first day of the month in which the
child's first birthday occurs to the last day of the month in
which the child becomes 18 years old.
(b) [EXPANSION OF ELIGIBILITY.] Eligibility for
MinnesotaCare shall be expanded as provided in subdivisions 2 to
5, except children who meet the criteria in this subdivision
shall continue to be enrolled pursuant to this subdivision. The
enrollment requirements in this paragraph apply to enrollment
under subdivisions 1 to 5. Parents who enroll in the
MinnesotaCare program must also enroll their children and
dependent siblings, if the children and their dependent siblings
are eligible. Children and dependent siblings may be enrolled
separately without enrollment by parents. However, if one
parent in the household enrolls, both parents must enroll,
unless other insurance is available. If one child from a family
is enrolled, all children must be enrolled, unless other
insurance is available. If one spouse in a household enrolls,
the other spouse in the household must also enroll, unless other
insurance is available. Families cannot choose to enroll only
certain uninsured members. For purposes of this section, a
"dependent sibling" means an unmarried child who is a full-time
student under the age of 25 years who is financially dependent
upon a parent. Proof of school enrollment will be required.
(c) [CONTINUATION OF ELIGIBILITY.] Individuals who
initially enroll in the MinnesotaCare program under the
eligibility criteria in subdivisions 2 to 5 remain eligible for
the MinnesotaCare program, regardless of age, place of
residence, or the presence or absence of children in the same
household, as long as all other eligibility criteria are met and
residence in Minnesota and continuous enrollment in the
MinnesotaCare program or medical assistance are maintained. In
order for either parent or either spouse in a household to
remain enrolled, both must remain enrolled, unless other
insurance is available.
Sec. 7. Minnesota Statutes 1994, section 256.9354,
subdivision 4, is amended to read:
Subd. 4. [FAMILIES WITH CHILDREN; ELIGIBILITY BASED ON
PERCENTAGE OF INCOME PAID FOR HEALTH COVERAGE.] Beginning
January 1, 1993, "eligible persons" means children, parents, and
dependent siblings residing in the same household who are not
eligible for medical assistance without a spenddown under
chapter 256B. Children who meet the criteria in subdivision
1 or 4a shall continue to be enrolled pursuant to subdivision 1
those subdivisions. Persons who are eligible under this
subdivision or subdivision 2, 3, or 5 must pay a premium as
determined under sections 256.9357 and 256.9358, and children
eligible under subdivision 1 must pay the premium required under
section 256.9356, subdivision 1. Individuals and families whose
income is greater than the limits established under section
256.9358 may not enroll in MinnesotaCare.
Sec. 8. Minnesota Statutes 1994, section 256.9354, is
amended by adding a subdivision to read:
Subd. 4a. [CHILDREN WITH LOWER INCOMES.] Beginning July 1,
1993, the definition of "eligible persons" is expanded to
include children who are one year of age or older but less than
18 years of age who have gross family incomes that are equal to
or less than 150 percent of the federal poverty guidelines and
who are not eligible for medical assistance without a spenddown
under chapter 256B and who are not otherwise insured for the
covered services. The period of eligibility extends from the
first day of the month in which the child's first birthday
occurs to the last day of the month in which the child becomes
18 years old. The commissioner shall exclude all earned income
of dependent children who:
(1) are full-time or part-time students;
(2) are employed for less than 37.5 hours per week; and
(3) earn less than $10,000 a year in total from all sources
of employment, when calculating gross family incomes for
applicants who would otherwise be eligible under this
subdivision.
Sec. 9. Minnesota Statutes 1994, section 256.9354,
subdivision 5, is amended to read:
Subd. 5. [ADDITION OF SINGLE ADULTS AND HOUSEHOLDS WITH NO
CHILDREN.] (a) Beginning October 1, 1994, the definition
of "eligible persons" shall is expanded to include all
individuals and households with no children who have gross
family incomes that are equal to or less than 125 percent of the
federal poverty guidelines and who are not eligible for medical
assistance without a spenddown under chapter 256B.
(b) Beginning October 1, 1995, "eligible persons" means all
individuals and families who are not eligible for medical
assistance without a spenddown under chapter 256B. After
October 1, 1995, the commissioner of human services may expand
the definition of "eligible persons" to include all individuals
and households with no children who have gross family incomes
that are equal to or less than 135 percent of federal poverty
guidelines and are not eligible for medical assistance without a
spenddown under chapter 256B. This expansion may occur only if
the financial management requirements of section 256.9352,
subdivision 3, can be met.
(c) The commissioners of health and human services, in
consultation with the legislative commission on health care
access, shall make preliminary recommendations to the
legislature by October 1, 1995, and final recommendations to the
legislature by February 1, 1996, on whether a further expansion
of the definition of "eligible persons" to include all
individuals and households with no children who have gross
family incomes that are equal to or less than 150 percent of
federal poverty guidelines and are not eligible for medical
assistance without a spenddown under chapter 256B would be
allowed under the financial management constraints outlined in
section 256.9352, subdivision 3.
(c) (d) All eligible persons under paragraphs (a) and (b)
are eligible for coverage through the MinnesotaCare program but
must pay a premium as determined under sections 256.9357 and
256.9358. Individuals and families whose income is greater than
the limits established under section 256.9358 may not enroll in
the MinnesotaCare program.
Sec. 10. Minnesota Statutes 1994, section 256.9355,
subdivision 2, is amended to read:
Subd. 2. [COMMISSIONER'S DUTIES.] The commissioner shall
use individuals' social security numbers as identifiers for
purposes of administering the plan and conduct data matches to
verify income. Applicants shall submit evidence of family
income, earned and unearned, including the most recent income
tax return, wage slips, or other documentation that is necessary
to verify income eligibility. The commissioner shall perform
random audits to verify reported income and eligibility. The
commissioner may execute data sharing arrangements with the
department of revenue and any other governmental agency in order
to perform income verification related to eligibility and
premium payment under the MinnesotaCare program.
Sec. 11. Minnesota Statutes 1994, section 256.9357,
subdivision 1, is amended to read:
Subdivision 1. [GENERAL REQUIREMENTS.] Families and
individuals are eligible for subsidized premium payments based
on a sliding scale under section 256.9358 only if the family or
individual meets the requirements in subdivisions 2 and
3. Families and individuals who enroll on or after October 1,
1992, are eligible for subsidized premium payments based on a
sliding scale under section 256.9358 only if the family or
individual meets the requirements in subdivisions 2 and 3.
Children already enrolled in the children's health plan as of
September 30, 1992, eligible under section 256.9354, subdivision
1, paragraph (a), children who enroll in the MinnesotaCare
program after September 30, 1992, pursuant to Laws 1992, chapter
549, article 4, section 17, and children who enroll under
section 256.9354, subdivision 4a, are eligible for subsidized
premium payments without meeting these requirements, as long as
they maintain continuous coverage in the MinnesotaCare plan or
medical assistance.
Families and individuals who initially enrolled in
MinnesotaCare under section 256.9354, and whose income increases
above the limits established in section 256.9358, may continue
enrollment and pay the full cost of coverage.
Sec. 12. Minnesota Statutes 1994, section 256.9357,
subdivision 2, is amended to read:
Subd. 2. [MUST NOT HAVE ACCESS TO EMPLOYER-SUBSIDIZED
COVERAGE.] (a) To be eligible for subsidized premium payments
based on a sliding scale, a family or individual must not have
access to subsidized health coverage through an employer, and
must not have had access to subsidized health coverage through
an employer for the 18 months prior to application for
subsidized coverage under the MinnesotaCare program. The
requirement that the family or individual must not have had
access to employer-subsidized coverage during the previous 18
months does not apply if: (1) employer-subsidized coverage was
lost due to the death of an employee or divorce; (2)
employer-subsidized coverage was lost because an individual
became ineligible for coverage as a child or dependent; or (3)
employer-subsidized coverage was lost for reasons that would not
disqualify the individual for unemployment benefits under
section 268.09 and the family or individual has not had access
to employer-subsidized coverage since the layoff loss of
coverage. If employer-subsidized coverage was lost for reasons
that disqualify an individual for unemployment benefits under
section 268.09, children of that individual are exempt from the
requirement of no access to employer subsidized coverage for the
18 months prior to application, as long as the children have not
had access to employer subsidized coverage since the
disqualifying event. The requirement that the family or
individual must not have had access to employer-subsidized
coverage during the previous 18 months does apply if
employer-subsidized coverage is lost due to an employer
terminating health care coverage as an employee benefit.
(b) For purposes of this requirement, subsidized health
coverage means health coverage for which the employer pays at
least 50 percent of the cost of coverage for the employee,
excluding dependent coverage, or a higher percentage as
specified by the commissioner. Children are eligible for
employer-subsidized coverage through either parent, including
the noncustodial parent. The commissioner must treat employer
contributions to Internal Revenue Code Section 125 plans as
qualified employer subsidies toward the cost of health coverage
for employees for purposes of this subdivision.
Sec. 13. Minnesota Statutes 1994, section 256.9357,
subdivision 3, is amended to read:
Subd. 3. [PERIOD UNINSURED.] To be eligible for subsidized
premium payments based on a sliding scale, families and
individuals initially enrolled in the MinnesotaCare program
under section 256.9354, subdivisions 4 and 5, must have had no
health coverage for at least four months prior to application.
The commissioner may change this eligibility criterion for
sliding scale premiums without complying with rulemaking
requirements in order to remain within the limits of available
appropriations. The requirement of at least four months of no
health coverage prior to application for the MinnesotaCare
program does not apply to:
(1) families, children, and individuals who want to apply
for the MinnesotaCare program upon termination from the medical
assistance program, general assistance medical care program, or
coverage under a regional demonstration project for the
uninsured funded under section 256B.73, the Hennepin county
assured care program, or the Group Health, Inc., community
health plan. This subdivision does not apply to;
(2) families and individuals initially enrolled under
sections section 256.9354, subdivisions 1, paragraph (a), and 2,
or to;
(3) children enrolled pursuant to Laws 1992, chapter 549,
article 4, section 17; or
(4) individuals currently serving or who have served in the
military reserves, and dependents of these individuals, if these
individuals: (i) reapply for MinnesotaCare coverage after a
period of active military service during which they had been
covered by the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS); (ii) were covered under
MinnesotaCare immediately prior to obtaining coverage under
CHAMPUS; and (iii) have maintained continuous coverage.
Sec. 14. Minnesota Statutes 1994, section 256.9358,
subdivision 3, is amended to read:
Subd. 3. [SLIDING SCALES AFTER JUNE 30, 1993.] Beginning
July 1, 1993, the sliding scales begin with a premium of 1.5
percent of gross family income for individuals with incomes
below the limits for the medical assistance program set at
133-1/3 percent of the AFDC payment standard and proceed through
the following evenly spaced steps: 1.8, 2.3, 3.1, 3.8, 4.8,
5.9, 7.4, and 8.8. These percentages are matched to evenly
spaced income steps ranging from the medical assistance income
limit to a gross monthly income of $1,600 for an individual,
$2,160 for a household of two, $2,720 for a household of three,
$3,280 for a household of four, and $3,840 for a household of
five, and $4,400 for households of six or more persons. For the
period October 1, 1992 through June 30, 1993, the commissioner
shall employ a sliding scale that sets required premiums at
percentages of gross family income equal to two-thirds of the
percentages specified in this subdivision.
Sec. 15. Minnesota Statutes 1994, section 256.9358,
subdivision 4, is amended to read:
Subd. 4. [INELIGIBILITY.] Families with children whose
gross monthly income is above the amount specified in
subdivision 3 are not eligible for the plan. Beginning October
1, 1994, an individual or households with no children whose
gross monthly income is greater than $767 for a single
individual and $1,025 for a married couple without children are
ineligible for the plan. Beginning October 1, 1995, an
individual or families whose gross monthly income is above the
amount specified in subdivision 3 are not eligible for the
plan greater than 125 percent of the federal poverty guidelines
are ineligible for the plan.
Sec. 16. Minnesota Statutes 1994, section 256.9358, is
amended by adding a subdivision to read:
Subd. 7. [MINIMUM PREMIUM PAYMENT.] Beginning with premium
payments due on or after July 1, 1995, the commissioner shall
require all MinnesotaCare enrollees to pay a minimum premium of
$4 per month.
Sec. 17. Minnesota Statutes 1994, section 256.9363,
subdivision 5, is amended to read:
Subd. 5. [ELIGIBILITY FOR OTHER STATE PROGRAMS.]
MinnesotaCare enrollees who become eligible for medical
assistance or general assistance medical care will remain in the
same managed care plan if the managed care plan has a contract
for that population. Contracts between the department of human
services and managed care plans must include MinnesotaCare, and
medical assistance and may, at the option of the commissioner of
human services, also include general assistance medical care.
Sec. 18. [256.9366] [ELIGIBILITY FOR MINNESOTACARE FOR
FAMILIES AND CHILDREN UNDER THE MINNESOTACARE HEALTH CARE REFORM
WAIVER.]
Subdivision 1. [FAMILIES WITH CHILDREN; IN
GENERAL.] Families with children with family income equal to or
less than 275 percent of the federal poverty guidelines for the
applicable family size shall be determined eligible for
MinnesotaCare according to this section, and section 256.9354,
subdivisions 2 to 4a, shall no longer apply. All other
provisions of sections 256.9351 to 256.9363, including the
insurance-related barriers to enrollment under section 256.9357,
shall apply unless otherwise specified in sections 256.9366 to
256.9369.
Subd. 2. [CHILDREN.] For purposes of sections 256.9366 to
256.9369, a "child" is an individual under 21 years of age,
including the unborn child of a pregnant woman, and including an
emancipated minor, and the emancipated minor's spouse.
Subd. 3. [FAMILIES WITH CHILDREN.] For purposes of
sections 256.9366 to 256.9369, a "family with children" means a
parent or parents and their children, or legal guardians and
their wards who are children, and dependent siblings, residing
in the same household. The term includes children and dependent
siblings who are temporarily absent from the household in
settings such as schools, camps, or visitation with noncustodial
parents. For purposes of this section, a "dependent sibling"
means an unmarried child who is a full-time student under the
age of 25 years who is financially dependent upon a parent.
Proof of school enrollment will be required.
Subd. 4. [CHILDREN IN FAMILIES WITH INCOME AT OR LESS THAN
150 PERCENT OF FEDERAL POVERTY GUIDELINES.] Children who have
gross family incomes that are equal to or less than 150 percent
of the federal poverty guidelines and who are not otherwise
insured for the covered services, are eligible for enrollment
under sections 256.9366 to 256.9369. For the purposes of this
section, "not otherwise insured for covered services" has the
meaning given in Minnesota Rules, part 9506.0020, subpart 3,
item B.
Subd. 5. [RESIDENCY.] Families and children who are
otherwise eligible for enrollment under section 256.9366 are
exempt from the Minnesota residency requirements of section
256.9359, if they meet the residency requirements of the medical
assistance program according to chapter 256B.
Subd. 6. [COOPERATION WITH MEDICAL ASSISTANCE.] Pregnant
women and children applying for MinnesotaCare under this section
are not required to apply for the medical assistance program as
a condition of enrollment. Other adults enrolled in
MinnesotaCare determined by the commissioner to have a basis of
eligibility for medical assistance must cooperate in completing
an application for medical assistance by the last day of the
third month following admission to an inpatient hospital. If an
enrollee fails to complete an application for medical assistance
within this time period, the enrollee shall be disenrolled and
may not reenroll.
Subd. 7. [COOPERATION IN ESTABLISHING PATERNITY AND OTHER
MEDICAL SUPPORT.] Families and children enrolled in the
MinnesotaCare program must cooperate with the department of
human services and the local agency in establishing paternity of
an enrolled child and in obtaining medical care support and
payments for the child and any other person for whom the person
can legally assign rights, in accordance with applicable laws
and rules governing the medical assistance program. A child
shall not be ineligible for or disenrolled from the
MinnesotaCare program solely because of the child's parent or
caretaker's failure to cooperate in establishing paternity or
obtaining medical support.
Sec. 19. [256.9367] [COVERED SERVICES FOR PREGNANT WOMEN
AND CHILDREN UNDER THE MINNESOTACARE HEALTH CARE REFORM WAIVER.]
Children and pregnant women are eligible for coverage of
all services that are eligible for reimbursement under the
medical assistance program according to chapter 256B. Pregnant
women and children are exempt from the provisions of section
256.9353, subdivision 7, regarding copayments.
Sec. 20. [256.9368] [PREMIUMS.]
Subdivision 1. [PREMIUM DETERMINATION.] Families and
children enrolled according to sections 256.9366 to 256.9369
shall pay a premium determined according to a sliding fee based
on the cost of coverage as a percentage of the family's gross
family income. Pregnant women and children under age two are
exempt from the provisions of section 256.9356, subdivision 3,
clause (3), requiring disenrollment for failure to pay
premiums. For pregnant women, this exemption continues until
the first day of the month following the 60th day postpartum.
Women who remain enrolled during pregnancy or the postpartum
period, despite nonpayment of premiums, shall be disenrolled on
the first of the month following the 60th day postpartum for the
penalty period that otherwise applies under section 256.9356.
Subd. 2. [SLIDING SCALE TO DETERMINE PERCENTAGE OF GROSS
FAMILY INCOME.] The commissioner shall establish a sliding fee
scale to determine the percentage of gross family income that
households at different income levels must pay to obtain
coverage through the MinnesotaCare program. The sliding fee
scale must be based on the enrollee's gross family income during
the previous four months. The sliding fee scale begins with a
premium of 1.5 percent of gross family income for families with
incomes below the limits for the medical assistance program for
families and children and proceeds through the following evenly
spaced steps: 1.8, 2.3, 3.1, 3.8, 4.8, 5.9, 7.4, and 8.8
percent. These percentages are matched to evenly spaced income
steps ranging from the medical assistance income limit for
families and children to 275 percent of the federal poverty
guidelines for the applicable family size. The sliding fee
scale and percentages are not subject to the provisions of
chapter 14. If a family reports increased income after
enrollment, premiums shall not be adjusted until eligibility
renewal.
Subd. 3. [EXCEPTIONS TO SLIDING SCALE.] An annual premium
of $48 is required for all children who are eligible according
to section 256.9366, subdivision 4.
Sec. 21. [256.9369] [PAYMENT RATES; SERVICES FOR FAMILIES
AND CHILDREN UNDER THE MINNESOTACARE HEALTH CARE REFORM WAIVER.]
Section 256.9362, subdivision 2, shall not apply to
services provided to children who are eligible to receive
expanded services according to section 256.9367.
Sec. 22. Minnesota Statutes 1994, section 256B.037,
subdivision 1, is amended to read:
Subdivision 1. [CONTRACT FOR DENTAL SERVICES.] The
commissioner may conduct a demonstration project to contract, on
a prospective per capita payment basis, with an organization or
organizations licensed under chapter 62C or, 62D, or 62N for the
provision of all dental care services beginning July 1, 1994,
under the medical assistance, general assistance medical care,
and MinnesotaCare programs, or when necessary waivers are
granted by the secretary of health and human services, whichever
occurs later. The commissioner shall identify a geographic area
or areas, including both urban and rural areas, where access to
dental services has been inadequate, in which to conduct
demonstration projects. The commissioner shall seek any federal
waivers or approvals necessary to implement this section from
the secretary of health and human services.
The commissioner may exclude from participation in the
demonstration project any or all groups currently excluded from
participation in the prepaid medical assistance program under
section 256B.69. Except for persons excluded from participation
in the demonstration project, all persons who have been
determined eligible for medical assistance, general assistance
medical care and, if applicable, MinnesotaCare and reside in the
designated geographic areas are required to enroll in a dental
plan to receive their dental care services. Except for
emergency services or out-of-plan services authorized by the
dental plan, recipients must receive their dental services from
dental care providers who are part of the dental plan provider
network.
The commissioner shall select either multiple dental plans
or a single dental plan in a designated area. A dental plan
under contract with the department must serve both medical
assistance recipients and general assistance medical care
recipients in a designated geographic area and may serve
MinnesotaCare recipients. The commissioner may limit the number
of dental plans with which the department contracts within a
designated geographic area, taking into consideration the number
of recipients within the designated geographic area; the number
of potential dental plan contractors; the size of the provider
network offered by dental plans; the dental care services
offered by a dental plan; qualifications of dental plan
personnel; accessibility of services to recipients; dental plan
assurances of recipient confidentiality; dental plan marketing
and enrollment activities; dental plan compliance with this
section; dental plan performance under other contracts with the
department to serve medical assistance, general assistance
medical care, or MinnesotaCare recipients; or any other factors
necessary to provide the most economical care consistent with
high standards of dental care.
For purposes of this section, "dental plan" means an
organization licensed under chapter 62C, 62D, or 62N that
contracts with the department to provide covered dental care
services to recipients on a prepaid capitation basis.
"Emergency services" has the meaning given in section 256B.0625,
subdivision 4. "Multiple dental plan area" means a designated
area in which more than one dental plan is offered.
"Participating provider" means a dentist or dental clinic who is
employed by or under contract with a dental plan to provide
dental care services to recipients. "Single dental plan area"
means a designated area in which only one dental plan is
available.
Sec. 23. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 1a. [MULTIPLE DENTAL PLAN AREAS.] After the
department has executed contracts with dental plans to provide
covered dental care services in a multiple dental plan area, the
department shall:
(1) inform applicants and recipients, in writing, of
available dental plans, when written notice of dental plan
selection must be submitted to the department, and when dental
plan participation begins;
(2) randomly assign to a dental plan recipients who fail to
notify the department in writing of their dental plan choice;
and
(3) notify recipients, in writing, of their assigned dental
plan before the effective date of the recipient's dental plan
participation.
Sec. 24. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 1b. [SINGLE DENTAL PLAN AREAS.] After the department
has executed a contract with a dental plan to provide covered
dental care services as the sole dental plan in a geographic
area, the provisions in paragraphs (a) to (c) apply.
(a) The department shall assure that applicants and
recipients are informed, in writing, of participating providers
in the dental plan and when dental plan participation begins.
(b) The dental plan may require the recipient to select a
specific dentist or dental clinic and may assign to a specific
dentist or dental clinic recipients who fail to notify the
dental plan of their selection.
(c) The dental plan shall notify recipients in writing of
their assigned providers before the effective date of dental
plan participation.
Sec. 25. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 1c. [DENTAL CHOICE.] (a) In multiple dental plan
areas, recipients may change dental plans once within the first
year the recipient participates in a dental plan. After the
first year of dental plan participation, recipients may change
dental plans during the annual 30-day open enrollment period.
(b) In single dental plan areas, recipients may change
their specific dentist or clinic at least once during the first
year of dental plan participation. After the first year of
dental plan participation, recipients may change their specific
dentist or clinic at least once annually. The dental plan shall
notify recipients of this change option.
(c) If a dental plan's contract with the department is
terminated for any reason, recipients in that dental plan shall
select a new dental plan and may change dental plans or a
specific dentist or clinic within the first 60 days of
participation in the second dental plan.
(d) Recipients may change dental plans or a specific
dentist or clinic at any time as follows:
(1) in multiple dental plan areas, if the travel time from
the recipient's residence to a general practice dentist is over
30 minutes, the recipient may change dental plans;
(2) in single dental plan areas, if the travel time from
the recipient's residence to the recipient's specific dentist or
clinic is over 30 minutes, the recipient may change providers;
or
(3) if the recipient's dental plan or specific dentist or
clinic was incorrectly designated due to department or dental
plan error.
(e) Requests for change under this subdivision must be
submitted to the department or dental plan in writing. The
department or dental plan shall notify recipients whether the
request is approved or denied within 30 days after receipt of
the written request.
Sec. 26. Minnesota Statutes 1994, section 256B.037,
subdivision 3, is amended to read:
Subd. 3. [APPEALS.] All recipients of services under this
section have the right to appeal to the commissioner under
section 256.045. A recipient participating in a dental plan may
utilize the dental plan's internal complaint procedure but is
not required to exhaust the internal complaint procedure before
appealing to the commissioner. The appeal rights and procedures
in Minnesota Rules, part 9500.1463, apply to recipients who
enroll in dental plans.
Sec. 27. Minnesota Statutes 1994, section 256B.037,
subdivision 4, is amended to read:
Subd. 4. [INFORMATION REQUIRED BY COMMISSIONER.] A
contractor shall submit encounter-specific information as
required by the commissioner, including, but not limited to,
information required for assessing client satisfaction, quality
of care, and cost and utilization of services. Dental plans and
participating providers must provide the commissioner access to
recipient dental records to monitor compliance with the
requirements of this section.
Sec. 28. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 6. [RECIPIENT COSTS.] A dental plan and its
participating providers or nonparticipating providers who
provide emergency services or services authorized by the dental
plan shall not charge recipients for any costs for covered
services.
Sec. 29. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 7. [FINANCIAL ACCOUNTABILITY.] A dental plan is
accountable to the commissioner for the fiscal management of
covered dental care services. The state of Minnesota and
recipients shall be held harmless for the payment of obligations
incurred by a dental plan if the dental plan or a participating
provider becomes insolvent and the department has made the
payments due to the dental plan under the contract.
Sec. 30. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 8. [QUALITY IMPROVEMENT.] A dental plan shall have
an internal quality improvement system. A dental plan shall
permit the commissioner or the commissioner's agents to evaluate
the quality, appropriateness, and timeliness of covered dental
care services through inspections, site visits, and review of
dental records.
Sec. 31. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 9. [THIRD-PARTY LIABILITY.] To the extent required
under section 62A.046 and Minnesota Rules, part 9506.0080, a
dental plan shall coordinate benefits for or recover the cost of
dental care services provided recipients who have other dental
care coverage. Coordination of benefits includes the dental
plan paying applicable copayments or deductibles on behalf of a
recipient.
Sec. 32. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 10. [FINANCIAL CAPACITY.] A dental plan shall
demonstrate that its financial risk capacity is acceptable to
its participating providers; except, an organization licensed as
a health maintenance organization under chapter 62D, a nonprofit
health service plan under chapter 62C, or an integrated service
network or a community integrated service network under chapter
62N, is not required to demonstrate financial risk capacity
beyond the requirements in those chapters for licensure or a
certificate of authority.
Sec. 33. Minnesota Statutes 1994, section 256B.037, is
amended by adding a subdivision to read:
Subd. 11. [DATA PRIVACY.] The contract between the
commissioner and the dental plan must specify that the dental
plan is an agent of the welfare system and shall have access to
welfare data on recipients to the extent necessary to carry out
the dental plan's responsibilities under the contract. The
dental plan shall comply with chapter 13, the Minnesota
government data practices act.
Sec. 34. Minnesota Statutes 1994, section 256B.04, is
amended by adding a subdivision to read:
Subd. 18. [APPLICATIONS FOR MEDICAL ASSISTANCE.] The state
agency may take applications for medical assistance and conduct
eligibility determinations for MinnesotaCare enrollees who are
required to apply for medical assistance according to section
256.9353, subdivision 3, paragraph (b).
Sec. 35. Minnesota Statutes 1994, section 256B.055, is
amended by adding a subdivision to read:
Subd. 10a. [CHILDREN.] This subdivision supersedes
subdivision 10, as long as the Minnesota health care reform
waiver remains in effect. When the waiver expires, this
subdivision expires and the commissioner of human services shall
publish a notice in the State Register and notify the revisor of
statutes. Medical assistance may be paid for a child less than
two years of age, whose mother was eligible for and receiving
medical assistance at the time of birth and who remains in the
mother's household or who is in a family with countable income
that is equal to or less than the income standard established
under section 256B.057, subdivision 1.
Sec. 36. Minnesota Statutes 1994, section 256B.057, is
amended by adding a subdivision to read:
Subd. 1b. [PREGNANT WOMEN AND INFANTS; EXPANSION.] This
subdivision supersedes subdivision 1 as long as the Minnesota
health care reform waiver remains in effect. When the waiver
expires, the commissioner of human services shall publish a
notice in the State Register and notify the revisor of
statutes. An infant less than two years of age or a pregnant
woman who has written verification of a positive pregnancy test
from a physician or licensed registered nurse, is eligible for
medical assistance if countable family income is equal to or
less than 275 percent of the federal poverty guideline for the
same family size. For purposes of this subdivision, "countable
family income" means the amount of income considered available
using the methodology of the AFDC program, except for the earned
income disregard and employment deductions. An amount equal to
the amount of earned income exceeding 275 percent of the federal
poverty guideline, up to a maximum of the amount by which the
combined total of 185 percent of the federal poverty guideline
plus the earned income disregards and deductions of the AFDC
program exceeds 275 percent of the federal poverty guideline
will be deducted for pregnant women and infants less than two
years of age. Eligibility for a pregnant woman or infant less
than two years of age under this subdivision must be determined
without regard to asset standards established in section
256B.056, subdivision 3.
An infant born on or after January 1, 1991, to a woman who
was eligible for and receiving medical assistance on the date of
the child's birth shall continue to be eligible for medical
assistance without redetermination until the child's second
birthday, as long as the child remains in the woman's household.
Sec. 37. Minnesota Statutes 1994, section 256B.057, is
amended by adding a subdivision to read:
Subd. 2b. [NO ASSET TEST FOR CHILDREN AND THEIR PARENTS;
EXPANSION.] This subdivision supersedes subdivision 2a as long
as the Minnesota health care reform waiver remains in effect.
When the waiver expires, this subdivision expires and the
commissioner of human services shall publish a notice in the
State Register and notify the revisor of statutes. Eligibility
for medical assistance for a person under age 21, and the
person's parents or relative caretakers as defined in the aid to
families with dependent children program according to chapter
256, who are eligible under section 256B.055, subdivision 3, and
who live in the same household as the person eligible under age
21, must be determined without regard to asset standards
established in section 256B.056.
Sec. 38. Minnesota Statutes 1994, section 256B.0625,
subdivision 30, is amended to read:
Subd. 30. [OTHER CLINIC SERVICES.] (a) Medical assistance
covers rural health clinic services, federally qualified health
center services, nonprofit community health clinic services,
public health clinic services, and the services of a clinic
meeting the criteria established in rule by the commissioner.
Rural health clinic services and federally qualified health
center services mean services defined in United States Code,
title 42, section 1396d(a)(2)(B) and (C). Payment for rural
health clinic and federally qualified health center services
shall be made according to applicable federal law and regulation.
(b) A federally qualified health center that is beginning
initial operation shall submit an estimate of budgeted costs and
visits for the initial reporting period in the form and detail
required by the commissioner. A federally qualified health
center that is already in operation shall submit an initial
report using actual costs and visits for the initial reporting
period. Within 90 days of the end of its reporting period, a
federally qualified health center shall submit, in the form and
detail required by the commissioner, a report of its operations,
including allowable costs actually incurred for the period and
the actual number of visits for services furnished during the
period, and other information required by the commissioner.
Federally qualified health centers that file Medicare cost
reports shall provide the commissioner with a copy of the most
recent Medicare cost report filed with the Medicare program
intermediary for the reporting year which support the costs
claimed on their cost report to the state.
(c) In order to continue cost-based payment under the
medical assistance program according to paragraphs (a) and (b),
a federally qualified health center or rural health clinic must
apply for designation as an essential community provider within
six months of final adoption of rules by the department of
health according to section 62Q.19, subdivision 7. For those
federally qualified health centers and rural health clinics that
have applied for essential community provider status within the
six-month time prescribed, medical assistance payments will
continue to be made according to paragraphs (a) and (b) for the
first three years of essential community provider status. For
federally qualified health centers and rural health clinics that
either do not apply within the time specified above, that are
denied essential community provider status by the department of
health, or who have had essential community provider status for
three years, medical assistance payments for health services
provided by these entities shall be according to the same rates
and conditions applicable to the same service provided by health
care providers that are not federally qualified health centers
or rural health clinics. This paragraph takes effect only if
the Minnesota health care reform waiver is approved by the
federal government, and remains in effect for as long as the
Minnesota health care reform waiver remains in effect. When the
waiver expires, this paragraph expires, and the commissioner of
human services shall publish a notice in the State Register and
notify the revisor of statutes.
Sec. 39. [256B.0645] [PROVIDER PAYMENTS; RETROACTIVE
CHANGES IN ELIGIBILITY.]
Payment to a provider for a health care service provided to
a general assistance medical care recipient who is later
determined eligible for medical assistance or MinnesotaCare
according to section 256.9367 for the period in which the health
care service was provided, shall be considered payment in full,
and shall not be adjusted due to the change in eligibility.
This section applies to both fee-for-service payments and
payments made to health plans on a prepaid capitated basis.
Sec. 40. Minnesota Statutes 1994, section 256B.69,
subdivision 2, is amended to read:
Subd. 2. [DEFINITIONS.] For the purposes of this section,
the following terms have the meanings given.
(a) "Commissioner" means the commissioner of human services.
For the remainder of this section, the commissioner's
responsibilities for methods and policies for implementing the
project will be proposed by the project advisory committees and
approved by the commissioner.
(b) "Demonstration provider" means an individual, agency,
organization, or group of these entities that participates in
the demonstration project according to criteria, standards,
methods, and other requirements established for the project and
approved by the commissioner.
(c) "Eligible individuals" means those persons eligible for
medical assistance benefits as defined in sections 256B.055,
256B.056, and 256B.06.
(d) "Limitation of choice" means suspending freedom of
choice while allowing eligible individuals to choose among the
demonstration providers.
(e) This paragraph supersedes paragraph (c) as long as the
Minnesota health care reform waiver remains in effect. When the
waiver expires, this paragraph expires and the commissioner of
human services shall publish a notice in the State Register and
notify the revisor of statutes. "Eligible individuals" means
those persons eligible for medical assistance benefits as
defined in sections 256B.055, 256B.056, and 256B.06.
Notwithstanding sections 256B.055, 256B.056, and 256B.06, an
individual who becomes ineligible for the program because of
failure to submit income reports or recertification forms in a
timely manner, shall remain enrolled in the prepaid health plan
and shall remain eligible to receive medical assistance coverage
through the last day of the month following the month in which
the enrollee became ineligible for the medical assistance
program.
Sec. 41. Minnesota Statutes 1994, section 256B.69,
subdivision 4, is amended to read:
Subd. 4. [LIMITATION OF CHOICE.] The commissioner shall
develop criteria to determine when limitation of choice may be
implemented in the experimental counties. The criteria shall
ensure that all eligible individuals in the county have
continuing access to the full range of medical assistance
services as specified in subdivision 6. The commissioner shall
exempt the following persons from participation in the project,
in addition to those who do not meet the criteria for limitation
of choice: (1) persons eligible for medical assistance
according to section 256B.055, subdivision 1, and children under
age 21 who are in foster placement; (2) persons eligible for
medical assistance due to blindness or disability as determined
by the social security administration or the state medical
review team, unless they are 65 years of age or older, or unless
they reside in Itasca county or they reside in a county in which
the commissioner conducts a pilot project under a waiver granted
pursuant to section 1115 of the Social Security Act; (3)
recipients who currently have private coverage through a health
maintenance organization; and (4) recipients who are eligible
for medical assistance by spending down excess income for
medical expenses other than the nursing facility per diem
expense. Before limitation of choice is implemented, eligible
individuals shall be notified and after notification, shall be
allowed to choose only among demonstration providers. After
initially choosing a provider, the recipient is allowed to
change that choice only at specified times as allowed by the
commissioner. If a demonstration provider ends participation in
the project for any reason, a recipient enrolled with that
provider must select a new provider but may change providers
without cause once more within the first 60 days after
enrollment with the second provider.
Sec. 42. Laws 1993, First Special Session chapter 1,
article 8, section 30, subdivision 2, is amended to read:
Subd. 2. Sections 1 to 3, 8, 9, 13 to 17, 22, 23, and 26
to 29 are effective July 1, 1994, contingent upon federal
recognition that group residential housing payments qualify as
optional state supplement payments to the supplemental security
income program under title XVI of the Social Security Act and
confer categorical eligibility for medical assistance under the
state plan for medical assistance. The amendments and repeals
by Laws 1993, First Special Session chapter 1, article 8,
sections 1 to 3, 8, 9, 13 to 17, 22, 23, 26, and 29, are
effective July 1, 1994.
Sec. 43. [MANAGED CARE IMPLEMENTATION PLANS.]
Prior to enrollment of medical assistance or general
assistance medical care recipients residing on an Indian
Reservation into managed care plans, the commissioner shall
consult with representatives of the Indian Reservation in
developing a plan to implement managed care in that community,
and shall present this implementation plan to the legislature
and to the legislative commission on health care access.
Sec. 44. [MINNESOTACARE PROGRAM ADMINISTRATION.]
The commissioner of administration shall study the
potential effectiveness of contracting with a private sector
third-party administrator to administer the MinnesotaCare
program. The commissioner shall determine whether the use of a
third-party administrator to determine enrollee eligibility and
process provider claims will reduce state administrative costs,
improve the accuracy and timeliness of eligibility determination
and claims payment, and allow effective coordination of
MinnesotaCare with the medical assistance program and county
social service agencies. The commissioner shall present
recommendations to the legislature by February 1, 1996.
Sec. 45. [WAIVER REQUEST.]
(a) The commissioner of human services shall seek federal
approval to add the benefit of drug coverage for qualified
Medicare beneficiaries with incomes up to 150 percent of the
federal poverty guidelines and to charge a copayment for this
benefit.
(b) If federal approval is obtained, the commissioner of
human services shall report to the legislature and present draft
legislation expanding the qualified Medicare beneficiary program
to the legislature for approval.
Sec. 46. [REPEALER.]
Minnesota Statutes 1994, section 256.9353, subdivisions 4
and 5, are repealed.
Sec. 47. [EFFECTIVE DATE.]
Sections 18 to 21 (256.9366 to 256.9369), 35, 36, 37, and
38 (256B.055, subdivision 10a; 256B.057, subdivision 1b;
256B.057, subdivision 2b; and 256B.0625, subdivision 30) are
effective July 1, 1995. The commissioner of human services
shall publish a notice in the State Register and notify the
revisor of statutes when the waiver expires and the provisions
in this section expire.
ARTICLE 7
INSURANCE REFORM
Section 1. Minnesota Statutes 1994, section 60A.02, is
amended by adding a subdivision to read:
Subd. 29. [MULTIPLE EMPLOYER TRUST.] "Multiple employer
trust" means a trust organized for the benefit of two or more
employers for the purpose of providing health insurance coverage
to employees and dependents.
Sec. 2. Minnesota Statutes 1994, section 62A.10,
subdivision 1, is amended to read:
Subdivision 1. [REQUIREMENTS.] Group accident and health
insurance is hereby declared to be that form of accident and
health insurance covering not less than two employees nor less
than ten members, and which may include the employee's or
member's dependents, consisting of husband, wife, children, and
actual dependents residing in the household, written under a
master policy issued to any governmental corporation, unit,
agency, or department thereof, or to any corporation,
copartnership, individual, employer, or to a purchasing pool as
described in section 62Q.17, to any association as defined by
section 60A.02, subdivision 1a, or to a multiple employer trust,
or to the trustee of a fund, established or adopted by two or
more employers or maintained for the benefit of members of an
association, where officers, members, employees, or classes or
divisions thereof, may be insured for their individual benefit.
Any insurer authorized to write accident and health
insurance in this state shall have power to issue group accident
and health policies.
Sec. 3. Minnesota Statutes 1994, section 62A.10,
subdivision 2, is amended to read:
Subd. 2. [POLICY FORMS.] No policy or certificate of group
accident and health insurance may be issued or delivered in this
state unless the same has been approved by the commissioner in
accordance with section 62A.02, subdivisions 1 to 6. These
forms shall contain the standard provisions relating and
applicable to health and accident insurance and shall conform
with the other requirements of law relating to the contents and
terms of policies of accident and sickness insurance in so far
as they may be applicable to group accident and health
insurance, and also the following provisions:
(1) [ENTIRE CONTRACT.] A provision that the policy and the
application of the employer, trustee, or executive officer or
trustee of any association, and the individual applications, if
any, of the employees or members insured, shall constitute the
entire contract between the parties, and that all statements
made by the employer, trustee, or any executive officer or
trustee in behalf of the group to be insured, shall, in the
absence of fraud, be deemed representations and not warranties,
and that no such statement shall be used in defense to a claim
under the policy, unless it is contained in the written
application;
(2) [MASTER POLICY-CERTIFICATES.] A provision that the
insurer will issue a master policy to the employer, trustee, or
to the executive officer or trustee of the association; and the
insurer shall also issue to the employer, trustee, or to the
executive officer or trustee of the association, for delivery to
the employee or member who is insured under the policy, an
individual certificate setting forth a statement as to the
insurance protection to which the employee or member is entitled
and to whom payable, together with a statement as to when and
where the master policy, or a copy thereof, may be seen for
inspection by the individual insured; this individual
certificate may contain the names of, and insure the dependents
of, the employee or member, as provided for herein;
(3) [NEW INSUREDS.] A provision that to the group or class
thereof originally insured may be added, from time to time, all
new employees of the employer or members of the association
eligible to and applying for insurance in that group or class
and covered or to be covered by the master policy.
Sec. 4. Minnesota Statutes 1994, section 62A.65,
subdivision 5, is amended to read:
Subd. 5. [PORTABILITY 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 or, preexisting
condition exclusion, or exclusionary rider, unless the
limitation or exclusion is permitted under this subdivision,
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 individual 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 has maintained continuous coverage may be
subjected to a one-time 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
must not be subject to any preexisting condition limitation or,
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.
(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. 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 or, 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
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
90 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. 5. Minnesota Statutes 1994, section 62A.65,
subdivision 8, is amended to read:
Subd. 8. [CESSATION OF INDIVIDUAL BUSINESS.]
Notwithstanding the provisions of subdivisions 1 to 7, a health
carrier may elect to cease doing business in the
individual health plan market in this state if it complies with
the requirements of this subdivision. For purposes of this
section, "cease doing business" means to discontinue issuing new
individual health plans and to refuse to renew all of the health
carrier's existing individual health plans issued in this state
whose terms permit refusal to renew under the circumstances
specified in this subdivision. This subdivision does not permit
cancellation of an individual health plan, unless the terms of
the health plan permit cancellation under the circumstances
specified in this subdivision. A health carrier electing to
cease doing business in the individual health plan market in
this state shall notify the commissioner 180 days prior to the
effective date of the cessation. The cessation of business does
not include the failure of a health carrier to offer or issue
new business in the individual health plan market or continue an
existing product line in that market, provided that a health
carrier does not terminate, cancel, or fail to renew its current
individual health plan business or other product lines. A
health carrier electing to cease doing business in the
individual health plan market shall provide 120 days' written
notice to each policyholder covered by a an individual health
plan issued by the health carrier. A health carrier that ceases
to write new business in the individual health plan market shall
continue to be governed by this section with respect to
continuing individual health plan business conducted by the
health carrier. A health carrier that ceases to do business in
the individual health plan market after July 1, 1994, is
prohibited from writing new business in the individual health
plan market in this state for a period of five years from the
date of notice to the commissioner. This subdivision applies to
any health maintenance organization that ceases to do business
in the individual health plan market in one service area with
respect to that service area only. Nothing in this subdivision
prohibits an affiliated health maintenance organization from
continuing to do business in the individual health plan market
in that same service area. The right to cancel or refuse to
renew an individual health plan under this subdivision does not
apply to individual health plans originally issued prior to July
1, 1993, on a guaranteed renewable basis that does not permit
refusal to renew under the circumstances specified in this
subdivision.
Sec. 6. Minnesota Statutes 1994, section 62D.02,
subdivision 8, is amended to read:
Subd. 8. "Health maintenance contract" means any contract
whereby a health maintenance organization agrees to provide
comprehensive health maintenance services to enrollees, provided
that the contract may contain reasonable enrollee copayment
provisions. An individual or group health maintenance contract
may contain the copayment and deductible provisions specified in
this subdivision. Copayment and deductible provisions in group
contracts shall not discriminate on the basis of age, sex, race,
length of enrollment in the plan, or economic status; and during
every open enrollment period in which all offered health benefit
plans, including those subject to the jurisdiction of the
commissioners of commerce or health, fully participate without
any underwriting restrictions, copayment and deductible
provisions shall not discriminate on the basis of preexisting
health status. In no event shall the sum of the annual
copayment copayments and deductible exceed the maximum
out-of-pocket expenses allowable for a number three
qualified insurance policy plan under section 62E.06, nor shall
that sum exceed $5,000 per family. The annual deductible must
not exceed $1,000 per person. The annual deductible must not
apply to preventive health services as described in Minnesota
Rules, part 4685.0801, subpart 8. Where sections 62D.01 to
62D.30 permit a health maintenance organization to contain
reasonable copayment provisions for preexisting health status,
these provisions may vary with respect to length of enrollment
in the plan. Any contract may provide for health care services
in addition to those set forth in subdivision 7.
Sec. 7. Minnesota Statutes 1994, section 62D.042,
subdivision 2, is amended to read:
Subd. 2. [BEGINNING ORGANIZATIONS.] (a) Beginning
organizations shall maintain net worth of at least 8-1/3 percent
of the sum of all expenses expected to be incurred in the 12
months following the date the certificate of authority is
granted, or $1,500,000, whichever is greater.
(b) After the first full calendar year of operation,
organizations shall maintain net worth of at least 8-1/3 percent
and at most 16-2/3 percent of the sum of all expenses incurred
during the most recent calendar year, but in no case shall net
worth fall below $1,000,000.
(c) Notwithstanding paragraphs (a) and (b), any health
maintenance organization owned by a political subdivision of
this state, which has a higher than average percentage of
enrollees who are enrolled in medical assistance or general
assistance medical care, may exceed the maximum net worth limits
provided in paragraphs (a) and (b), with the advance approval of
the commissioner.
Sec. 8. Minnesota Statutes 1994, section 62E.05, is
amended to read:
62E.05 [CERTIFICATION OF INFORMATION ON QUALIFIED PLANS.]
Subdivision 1. [CERTIFICATION.] Upon application by an
insurer, fraternal, or employer for certification of a plan of
health coverage as a qualified plan or a qualified medicare
supplement plan for the purposes of sections 62E.01 to 62E.16,
the commissioner shall make a determination within 90 days as to
whether the plan is qualified. All plans of health coverage,
except Medicare supplement policies, shall be labeled as
"qualified" or "nonqualified" on the front of the policy or
evidence of insurance. All qualified plans shall indicate
whether they are number one, two, or three coverage plans.
Subd. 2. [ANNUAL REPORT.] All health plan companies, as
defined in section 62Q.01, shall annually report to the
commissioner responsible for their regulation. The following
information shall be reported to the appropriate commissioner on
February 1 of each year:
(1) the number of individuals and groups who received
coverage in the prior year through the qualified plans; and
(2) the number of individuals and groups who received
coverage in the prior year through each of the unqualified plans
sold by the company.
Sec. 9. Minnesota Statutes 1994, section 62E.141, is
amended to read:
62E.141 [INCLUSION IN EMPLOYER-SPONSORED PLAN.]
No employee, or dependent of an employee, of an employer
that offers a health plan, under which the employee or dependent
is eligible for coverage, is eligible to enroll, or continue to
be enrolled, in the comprehensive health association, except for
enrollment or continued enrollment necessary to cover conditions
that are subject to an unexpired preexisting condition
limitation or, preexisting condition exclusion, or exclusionary
rider under the employer's health plan. This section does not
apply to persons enrolled in the comprehensive health
association as of June 30, 1993. With respect to persons
eligible to enroll in the health plan of an employer that has
more than 29 current employees, as defined in section 62L.02,
this section does not apply to persons enrolled in the
comprehensive health association as of December 31, 1994.
Sec. 10. Minnesota Statutes 1994, section 62H.04, is
amended to read:
62H.04 [COMPLIANCE WITH OTHER LAWS.]
A joint self-insurance plan is subject to the requirements
of chapters 62A, and 62E, and 62L, and sections 72A.17 to 72A.32
unless otherwise specifically exempt. A joint self-insurance
plan must not offer less than a number two qualified plan or its
actuarial equivalent.
Sec. 11. Minnesota Statutes 1994, section 62H.08, is
amended to read:
62H.08 [EXEMPTION.]
A homogenous joint employer plan providing group health
benefits, which was in existence prior to March 1, 1983, and
which is associated with, or organized or sponsored by, an
association exempt from taxation under United States Code, title
26, section 501(c)(6), and controlled by a board of trustees a
majority of whom are members of the association, is exempt from
the requirements of sections 62H.01 to 62H.08 and 471.617,
subdivisions 1 to 3, and the insurance laws of this state,
except that the association must comply with the provisions of
chapter 62L with respect to any members that are small employers.
Sec. 12. Minnesota Statutes 1994, section 62L.02,
subdivision 11, is amended to read:
Subd. 11. [DEPENDENT.] "Dependent" means an eligible
employee's spouse, unmarried child who is under the age of 19
years, unmarried child under the age of 25 years who is a
full-time student as defined in section 62A.301, dependent child
of any age who is handicapped 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 child may include includes a child for whom the
employee or the employee's spouse has been appointed legal
guardian.
Sec. 13. Minnesota Statutes 1994, section 62L.02,
subdivision 16, is amended to read:
Subd. 16. [HEALTH CARRIER.] "Health carrier" means 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 health service plan corporation licensed under
chapter 62C; a health maintenance organization licensed under
chapter 62D; a community integrated service network and an
integrated service network operating under chapter 62N; a
fraternal benefit society operating under chapter 64B; a joint
self-insurance employee health plan operating under chapter 62H;
and a multiple employer welfare arrangement, as defined in
United States Code, title 29, section 1002(40), as amended. For
purposes of sections 62L.01 to 62L.12, but not for purposes of
sections 62L.13 to 62L.22, "health carrier" includes community
integrated service network or integrated service network
licensed under chapter 62N. Any use of this definition in
another chapter by reference does not include a community
integrated service network or integrated service network, unless
otherwise specified. For the purpose of this chapter, companies
that are affiliated companies or that are eligible to file a
consolidated tax return must be treated as one health carrier,
except that any insurance company or health service plan
corporation that is an affiliate of a health maintenance
organization located in Minnesota, or any health maintenance
organization located in Minnesota that is an affiliate of an
insurance company or health service plan corporation, or any
health maintenance organization that is an affiliate of another
health maintenance organization in Minnesota, may treat the
health maintenance organization as a separate health carrier.
Sec. 14. Minnesota Statutes 1994, section 62L.02,
subdivision 24, is amended to read:
Subd. 24. [QUALIFYING COVERAGE.] "Qualifying coverage"
means health benefits or health coverage provided under:
(1) a health plan, as defined in this section;
(2) Medicare;
(3) medical assistance under chapter 256B;
(4) general assistance medical care under chapter 256D;
(5) MCHA;
(6) a self-insured health plan;
(7) the MinnesotaCare program established under section
256.9352, when the plan includes inpatient hospital services as
provided in section 256.9353;
(8) a plan provided under section 43A.316, 43A.317, or
471.617; or
(9) the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS);
(10) coverage provided by a health care network cooperative
under chapter 62R or by a health provider cooperative under
section 62R.17; or
(11) a plan similar to any of the above plans provided in
this state or in another state as determined by the commissioner.
Sec. 15. Minnesota Statutes 1994, section 62L.02,
subdivision 26, is amended to read:
Subd. 26. [SMALL EMPLOYER.] (a) "Small employer" means a
person, firm, corporation, partnership, association, or other
entity actively engaged in business, including a political
subdivision of the state, that, on at least 50 percent of its
working days during the preceding 12 months, employed no fewer
than two nor more than 29, or after June 30, 1995, more than 49,
current employees, the majority of whom were employed in this
state. If an employer has only two eligible employees and one
is the spouse, child, sibling, parent, or grandparent of the
other, the employer must be a Minnesota domiciled employer and
have paid social security or self-employment tax on behalf of
both eligible employees. If an employer has only one eligible
employee who has not waived coverage, the sale of a health plan
to or for that eligible employee is not a sale to a small
employer and is not subject to this chapter and may be treated
as the sale of an individual health plan. A small employer plan
may be offered through a domiciled association to self-employed
individuals and small employers who are members of the
association, even if the self-employed individual or small
employer has fewer than two current employees. Entities that
are eligible to file a combined tax return for purposes of state
tax laws are considered a single employer for purposes of
determining the number of current employees. Small employer
status must be determined on an annual basis as of the renewal
date of the health benefit plan. The provisions of this chapter
continue to apply to an employer who no longer meets the
requirements of this definition until the annual renewal date of
the employer's health benefit plan.
(b) Where an association, described as defined in section
62A.10, subdivision 1 62L.045, comprised of employers contracts
with a health carrier to provide coverage to its members who are
small employers, the association shall be considered to be a and
health benefit plans it provides to small employer employers,
are subject to section 62L.045, with respect to those small
employers in the association that employ no fewer than two nor
more than 29, or after June 30, 1995, more than 49, current
employees, even though the association also provides coverage to
its members that do not qualify as small employers. An
association in existence prior to July 1, 1993, is exempt from
this chapter with respect to small employers that are members as
of that date. However, in providing coverage to new employers
after July 1, 1993, the existing association must comply with
all requirements of this chapter. Existing associations must
register with the commissioner of commerce prior to July 1, 1993.
With respect to small employers having not fewer than 30 nor
more than 49 current employees, the July 1, 1993, date in this
paragraph becomes July 1, 1995, and the reference to "after"
that date becomes "on or after."
(c) If an employer has employees covered under a trust
specified in a collective bargaining agreement under the federal
Labor-Management Relations Act of 1947, United States Code,
title 29, section 141, et seq., as amended, or employees whose
health coverage is determined by a collective bargaining
agreement and, as a result of the collective bargaining
agreement, is purchased separately from the health plan provided
to other employees, those employees are excluded in determining
whether the employer qualifies as a small employer. Those
employees are considered to be a separate small employer if they
constitute a group that would qualify as a small employer in the
absence of the employees who are not subject to the collective
bargaining agreement.
Sec. 16. Minnesota Statutes 1994, section 62L.03,
subdivision 3, is amended to read:
Subd. 3. [MINIMUM PARTICIPATION AND CONTRIBUTION.] (a) A
small employer that has at least 75 percent of its eligible
employees who have not waived coverage participating in a health
benefit plan and that contributes at least 50 percent toward the
cost of coverage of each eligible employees employee must be
guaranteed coverage on a guaranteed issue basis from any health
carrier participating in the small employer market. The
participation level of eligible employees must be determined at
the initial offering of coverage and at the renewal date of
coverage. A health carrier must not increase the participation
requirements applicable to a small employer at any time after
the small employer has been accepted for coverage. For the
purposes of this subdivision, waiver of coverage includes only
waivers due to: (1) coverage under another group health plan;
(2) coverage under Medicare Parts A and B; or (3) coverage under
MCHA permitted under section 62E.141; or (4) coverage under
medical assistance under chapter 256B or general assistance
medical care under chapter 256D.
(b) If a small employer does not satisfy the contribution
or participation requirements under this subdivision, a health
carrier may voluntarily issue or renew individual health plans,
or a health benefit plan which must fully comply with this
chapter. A health carrier that provides a health benefit plan
to a small employer that does not meet the contribution or
participation requirements of this subdivision must maintain
this information in its files for audit by the commissioner. A
health carrier may not offer an individual health plan,
purchased through an arrangement between the employer and the
health carrier, to any employee unless the health carrier also
offers the individual health plan, on a guaranteed issue basis,
to all other employees of the same employer.
(c) Nothing in this section obligates a health carrier to
issue coverage to a small employer that currently offers
coverage through a health benefit plan from another health
carrier, unless the new coverage will replace the existing
coverage and not serve as one of two or more health benefit
plans offered by the employer.
Sec. 17. Minnesota Statutes 1994, section 62L.03,
subdivision 4, is amended to read:
Subd. 4. [UNDERWRITING RESTRICTIONS.] 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.
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 or, preexisting condition exclusion, or any
exclusionary rider. 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. Except as otherwise authorized for late
entrants, preexisting conditions may be excluded by a health
carrier for a period not to exceed 12 months from the effective
date of coverage of an eligible employee or dependent, but
exclusionary riders must not be used. When calculating a
preexisting condition limitation, a health carrier shall credit
the time period an eligible employee or dependent was previously
covered by qualifying prior coverage, provided that the
individual maintains continuous coverage. Late entrants may be
subject to a preexisting condition limitation not to exceed 18
months from the effective date of coverage of the late entrant,
but must not be subject to any exclusionary rider or preexisting
condition exclusion. 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.
Sec. 18. Minnesota Statutes 1994, section 62L.03,
subdivision 5, is amended to read:
Subd. 5. [CANCELLATIONS AND FAILURES TO RENEW.] (a) No
health carrier shall cancel, decline to issue, or fail to renew
a health benefit plan as a result of the claim experience or
health status of the persons covered or to be covered by the
health benefit plan.
(b) A health carrier may cancel or fail to renew a health
benefit plan:
(1) for nonpayment of the required premium;
(2) for fraud or misrepresentation by the small employer,
or, with respect to coverage of an individual eligible employee
or dependent, fraud or misrepresentation by the eligible
employee or dependent, with respect to eligibility for coverage
or any other material fact;
(3) if eligible employee participation during the preceding
calendar year declines to less than 75 percent, subject to the
waiver of coverage provision in subdivision 3;
(4) if the employer fails to comply with the minimum
contribution percentage required under subdivision 3; or
(4) for any other reasons or grounds expressly permitted by
the respective licensing laws and regulations governing a health
carrier, including, but not limited to, service area
restrictions imposed on health maintenance organizations under
section 62D.03, subdivision 4, paragraph (m), to the extent that
these grounds are not expressly inconsistent with this chapter.
(c) A health carrier may fail to renew a health benefit
plan:
(1) if eligible employee participation during the preceding
calendar year declines to less than 75 percent, subject to the
waiver of coverage provision in subdivision 3;
(5) (2) if the health carrier ceases to do business in the
small employer market under section 62L.09; or
(6) (3) if a failure to renew is based upon the health
carrier's decision to discontinue the health benefit plan form
previously issued to the small employer, but only if the health
carrier permits each small employer covered under the prior form
to switch to its choice of any other health benefit plan offered
by the health carrier, without any underwriting restrictions
that would not have been permitted for renewal purposes; or
(7) for any other reasons or grounds expressly permitted by
the respective licensing laws and regulations governing a health
carrier, including, but not limited to, service area
restrictions imposed on health maintenance organizations under
section 62D.03, subdivision 4, paragraph (m), to the extent that
these grounds are not expressly inconsistent with this chapter.
(b) (d) A health carrier need not renew a health benefit
plan, and shall not renew a small employer plan, if an employer
ceases to qualify as a small employer as defined in section
62L.02. If a health benefit plan, other than a small employer
plan, provides terms of renewal that do not exclude an employer
that is no longer a small employer, the health benefit plan may
be renewed according to its own terms. If a health carrier
issues or renews a health plan to an employer that is no longer
a small employer, without interruption of coverage, the health
plan is subject to section 60A.082.
Sec. 19. [62L.045] [ASSOCIATIONS.]
Subdivision 1. [DEFINITIONS.] For purposes of this
section, the following terms have the meanings given:
(a) "Association" means:
(1) an association as defined in section 60A.02;
(2) a group or organization of political subdivisions;
(3) an educational cooperative service unit created under
section 123.58; or
(4) a joint self-insurance pool authorized under section
471.617, subdivision 2.
(b) "Qualified association" means an association, as
defined in this subdivision, that:
(1) is registered with the commissioner of commerce;
(2) provides health plan coverage through a health carrier
that participates in the small employer market in this state,
other than through associations;
(3) has and adheres to membership and participation
criteria and health plan eligibility criteria that are not
designed to disproportionately include or attract small
employers that are likely to have low costs of health coverage
or to disproportionately exclude or repel small employers that
are likely to have high costs of health coverage; and
(4) permits any small employer that meets its membership,
participation, and eligibility criteria to become a member and
to obtain health plan coverage through the association.
Subd. 2. [QUALIFIED ASSOCIATIONS.] (a) A qualified
association, as defined in this section, and health benefit
plans offered by it, to it, or through it, to a small employer
in this state must comply with the requirements of this chapter
regarding guaranteed issue, guaranteed renewal, preexisting
condition limitations, credit against preexisting condition
limitations for continuous coverage, treatment of MCHA
enrollees, and the definition of dependent, and with section
62A.65, subdivision 5, paragraph (b). They must also comply
with all other requirements of this chapter not specifically
exempted in paragraph (b) or (c).
(b) A qualified association and a health carrier offering,
selling, issuing, or renewing a health benefit plan to, or to
cover, a small employer in this state through the qualified
association, may, but are not, in connection with that health
benefit plan, required to:
(1) offer the two small employer plans described in section
62L.05; and
(2) offer to small employers that are not members of the
association, health benefit plans offered to, by, or through the
qualified association.
(c) A qualified association, and a health carrier offering,
selling, issuing, and renewing a health benefit plan to, or to
cover, a small employer in this state must comply with section
62L.08, except that a separate index rate may be applied by a
health carrier to each qualified association, provided that:
(1) the premium rate applied to participating small
employer members of the qualified association is no more than 25
percent above and no more than 25 percent below the index rate
applied to the qualified association, irrespective of when
members applied for health coverage; and
(2) the index rate applied by a health carrier to a
qualified association is no more than 20 percent above and no
more than 20 percent below the index rate applied by the health
carrier to any other qualified association or to any small
employer. In comparing index rates for purposes of this clause,
the 20 percent shall be calculated as a percent of the larger
index rate.
Subd. 3. [OTHER ASSOCIATIONS.] Associations as defined in
this section that are not qualified associations; health benefit
plans offered, sold, issued, or renewed through them; and the
health carriers doing so, must fully comply with this chapter
with respect to small employers that are members of the
association.
Subd. 4. [PRINCIPLES; ASSOCIATION COVERAGE.] (a) This
subdivision applies to associations as defined in this section,
whether qualified associations or not, and is intended to
clarify subdivisions 1 to 3.
(b) This section applies only to associations that provide
coverage to small employers.
(c) The requirements of guaranteed issue and guaranteed
renewal apply to coverage issued to cover small employers and
persons covered through them, within the context of an
arrangement between an association and a health carrier. A
health carrier is not required under this chapter to comply with
guaranteed issue and guaranteed renewal with respect to its
relationship with the association itself. An arrangement
between the health carrier and the association, once entered
into, must comply with guaranteed issue and guaranteed renewal
with respect to members of the association that are small
employers and persons covered through them.
(d) When an arrangement between a health carrier and an
association has validly terminated, the health carrier has no
continuing obligation to small employers and persons covered
through them, except as otherwise provided in:
(1) section 62A.65, subdivision 5, paragraph (b);
(2) any other continuation or conversion rights applicable
under state or federal law; and
(3) section 60A.082, relating to group replacement
coverage, and rules adopted under that section.
(e) When an association's arrangement with a health carrier
has terminated and the association has entered into a new
arrangement with that health carrier or a different health
carrier, the new arrangement is subject to section 60A.082 and
rules adopted under it, with respect to members of the
association that are small employers and persons covered through
them.
(f) An association that offers its members more than one
health plan may have uniform rules restricting movement between
the health plans, if the rules do not discriminate against small
employers.
(g) This chapter does not require or prohibit separation of
an association's members into one group consisting only of small
employers and another group or other groups consisting of all
other members. The association must comply with this section
with respect to the small employer group.
(h) For purposes of this section, "member" of an
association includes an employer participant in the association.
(i) For purposes of this section, coverage issued to, or to
cover, a small employer includes a certificate of coverage
issued directly to the employer's employees and dependents,
rather than to the small employer.
Subd. 5. [REGISTRATION.] The commissioner may require all
associations that are subject to this section to register with
the commissioner prior to an initial purchase of coverage under
this section.
Sec. 20. Minnesota Statutes 1994, section 62L.09,
subdivision 1, is amended to read:
Subdivision 1. [NOTICE TO COMMISSIONER.] A health carrier
electing to cease doing business in the small employer market
shall notify the commissioner 180 days prior to the effective
date of the cessation. The health carrier shall simultaneously
provide a copy of the notice to each small employer covered by a
health benefit plan issued by the health carrier. For purposes
of this section, "cease doing business" means to discontinue
issuing new health benefit plans to small employers and to
refuse to renew all of the health carrier's existing health
benefit plans issued to small employers, the terms of which
permit refusal to renew under the circumstances specified in
this subdivision. This section does not permit cancellation of
a health benefit plan, unless permitted under its terms.
Upon making the notification, the health carrier shall not
offer or issue new business in the small employer market. The
health carrier shall renew its current small employer business
due for renewal within 120 days after the date of the
notification but shall not renew any small employer business
more than 120 days after the date of the notification. The
renewal period for business renewed during that 120-day period
shall end on the effective date of the cessation.
A health carrier that elects to cease doing business in the
small employer market shall continue to be governed by this
chapter with respect to any continuing small employer business
conducted by the health carrier.
Sec. 21. Minnesota Statutes 1994, section 62L.12,
subdivision 2, is amended to read:
Subd. 2. [EXCEPTIONS.] (a) A health carrier may sell,
issue, or renew individual conversion policies to eligible
employees and dependents otherwise eligible for conversion
coverage under section 62D.104 as a result of leaving a health
maintenance organization's service area.
(b) A health carrier may sell, issue, or renew individual
conversion policies to eligible employees and dependents
otherwise eligible for conversion coverage as a result of the
expiration of any continuation of group coverage required under
sections 62A.146, 62A.17, 62A.21, 62C.142, 62D.101, and 62D.105.
(c) A health carrier may sell, issue, or renew conversion
policies under section 62E.16 to eligible employees and
dependents.
(d) A health carrier may sell, issue, or renew individual
continuation policies to eligible employees and dependents as
required.
(e) A health carrier may sell, issue, or renew individual
health plans if the coverage is appropriate due to an unexpired
preexisting condition limitation or exclusion applicable to the
person under the employer's group health plan or due to the
person's need for health care services not covered under the
employer's group health plan.
(f) A health carrier may sell, issue, or renew an
individual health plan, if the individual has elected to buy the
individual health plan not as part of a general plan to
substitute individual health plans for a group health plan nor
as a result of any violation of subdivision 3 or 4.
(g) Nothing in this subdivision relieves a health carrier
of any obligation to provide continuation or conversion coverage
otherwise required under federal or state law.
(h) Nothing in this chapter restricts the offer, sale,
issuance, or renewal of coverage issued as a supplement to
Medicare under sections 62A.31 to 62A.44, or policies or
contracts that supplement Medicare issued by health maintenance
organizations, or those contracts governed by section 1833 or
1876 of the federal Social Security Act, United States Code,
title 42, section 1395 et. seq., as amended.
(i) Nothing in this chapter restricts the offer, sale,
issuance, or renewal of individual health plans necessary to
comply with a court order.
Sec. 22. Minnesota Statutes 1994, section 62L.17, is
amended by adding a subdivision to read:
Subd. 2a. [PARTICIPATION OF NEW SMALL EMPLOYER HEALTH
CARRIERS.] A health carrier that enters the small employer
market subsequent to February 1993, may elect to not participate
in the reinsurance association by filing an application within
60 days of entry into the small employer market or the effective
date of this section, whichever is later. The commissioner
shall make a determination and notify the health carrier no
later than 60 days after receipt of the application. In
determining whether to approve the application, the commissioner
shall consider the standards defined in subdivision 2, except
that the commissioner may also consider whether the health
carrier has a guaranteeing organization as defined in section
62D.043, subdivision 1, or as permitted under chapter 62N.
Sec. 23. Minnesota Statutes 1994, section 62L.18,
subdivision 2, is amended to read:
Subd. 2. [ELIGIBILITY FOR REINSURANCE.] (a) A health
carrier may not reinsure existing small employer business
through the association. A health carrier may reinsure an
employee or dependent who previously had coverage from MCHA who
is now eligible for coverage through the small employer group at
the time of enrollment as defined in section 62L.03, subdivision
6. A health carrier may not reinsure individuals who have
existing individual health care coverage with that health
carrier upon replacement of the individual coverage with group
coverage as provided in section 62L.04, subdivision 1.
(b) A health carrier may cede to the association the risk
of any newly eligible employees or continue to reinsure small
employer business for employers who, at the time of renewal of
coverage by the same health carrier prior to July 1, 1995, have
more than 29 current employees but fewer than 49 current
employees. This paragraph is effective retroactively for
coverage renewed on or after July 1, 1994.
Sec. 24. Minnesota Statutes 1994, section 62Q.17,
subdivision 2, is amended to read:
Subd. 2. [COMMON FACTORS.] All participants in a
purchasing pool must live within a common geographic region, be
employed in a similar occupation, or share some other common
factor as approved by the commissioner of commerce. The
membership criteria must not be designed to include
disproportionately employers, groups, or individuals likely to
have low costs of health coverage, or to exclude
disproportionately employers, groups, or individuals likely to
have high costs of health coverage.
Sec. 25. Minnesota Statutes 1994, section 62Q.17,
subdivision 8, is amended to read:
Subd. 8. [REPORTS.] Prior to the initial effective date of
coverage, and annually on July 1 thereafter, each pool shall
file a report with the information clearinghouse and the
commissioner of commerce. The information clearinghouse must
use the report to promote the purchasing pools. The annual
report must contain the following information:
(1) the number of lives in the pool;
(2) the geographic area the pool intends to cover;
(3) the number of health plans offered;
(4) a description of the benefits under each plan;
(5) a description of the premium structure, including any
copayments or deductibles, of each plan offered;
(6) evidence of compliance with chapter 62L;
(7) a sample of marketing information, including a phone
number where the pool may be contacted; and
(8) a list of all administrative fees charged.
Sec. 26. Minnesota Statutes 1994, section 62Q.17, is
amended by adding a subdivision to read:
Subd. 9. [ENFORCEMENT.] Purchasing pools must register
prior to offering coverage, and annually on July 1 thereafter,
with the commissioner of commerce on a form prescribed by the
commissioner. The commissioner of commerce shall enforce this
section and all other state laws with respect to purchasing
pools, and has for that purpose all general rulemaking and
enforcement powers otherwise available to the commissioner of
commerce. The commissioner may charge an annual registration
fee sufficient to meet the costs of the commissioner's duties
under this section.
Sec. 27. Minnesota Statutes 1994, section 72A.201, is
amended by adding a subdivision to read:
Subd. 13. [IMPROPER CLAIM OF DISCOUNT.] (a) No insurer,
integrated service network, or community integrated service
network shall intentionally provide a health care provider with
an explanation of benefits or similar document claiming a right
to a discounted fee, price, or other charge, when the insurer,
integrated service network, or community integrated service
network does not have an agreement with the provider for the
discount with respect to the patient involved.
(b) The insurer, integrated service network, or community
integrated service network may, notwithstanding paragraph (a),
claim the right to a discount based upon a discount agreement
between the health care provider and another entity, but only if:
(1) that agreement expressly permitted the entity to assign
its right to receive the discount;
(2) an assignment to the insurer, integrated service
network, or community integrated service network of the right to
receive the discount complies with any relevant requirements for
assignments contained in the discount agreement; and
(3) the insurer, integrated service network, or community
integrated service network has complied with any relevant
requirements contained in the assignment.
(c) When an explanation of benefits or similar document
claims a discount permitted under paragraph (b), it shall
prominently state that the discount claimed is based upon an
assignment and shall state the name of the entity from whom the
assignment was received. This paragraph does not apply if the
entity that issues the explanation of benefits or similar
document has a provider agreement with the provider.
(d) No insurer, integrated service network, or community
integrated service network that has entered into an agreement
with a health care provider that involves discounted fees,
prices, or other charges shall disclose the discounts to another
entity, with the knowledge or expectation that the disclosure
will result in claims for discounts prohibited under paragraphs
(a) and (b).
Sec. 28. [REPEALER; POLITICAL SUBDIVISION ASSOCIATIONS.]
Minnesota Statutes 1994, section 62L.08, subdivision 7a, is
repealed effective January 1, 1996.
Sec. 29. [EFFECTIVE DATES.]
Sections 1, 2, 3, 10, 11, 15, and 19 are effective January
1, 1996. Section 13 is effective retroactively to January 1,
1995. Sections 17 and 22 are effective the day following final
enactment. Section 23 is effective retroactively to July 1,
1994.
ARTICLE 8
RURAL HEALTH INITIATIVES AND MISCELLANEOUS PROVISIONS
Section 1. Minnesota Statutes 1994, section 62J.05,
subdivision 2, is amended to read:
Subd. 2. [MEMBERSHIP.] (a) [NUMBER.] The Minnesota health
care commission consists of 27 28 members, as specified in this
subdivision. A member may designate a representative to act as
a member of the commission in the member's absence. The
governor and legislature shall coordinate appointments under
this subdivision to ensure gender balance and ensure that
geographic areas of the state are represented in proportion to
their population.
(b) [HEALTH PLAN COMPANIES.] The commission includes four
members representing health plan companies, including one member
appointed by the Minnesota Council of Health Maintenance
Organizations, one member appointed by the Insurance Federation
of Minnesota, one member appointed by Blue Cross and Blue Shield
of Minnesota, and one member appointed by the governor.
(c) [HEALTH CARE PROVIDERS.] The commission includes six
members representing health care providers, including one member
appointed by the Minnesota Hospital Association, one member
appointed by the Minnesota Medical Association, one member
appointed by the Minnesota Nurses' Association, one rural
physician appointed by the governor, and two members appointed
by the governor to represent providers other than hospitals,
physicians, and nurses.
(d) [EMPLOYERS.] The commission includes four members
representing employers, including (1) two members appointed by
the Minnesota Chamber of Commerce, including one self-insured
employer and one small employer; and (2) two members appointed
by the governor.
(e) [CONSUMERS.] The commission includes seven consumer
members, including three members appointed by the governor, one
of whom must represent persons over age 65; one member appointed
by the consortium of citizens with disabilities to represent
consumers with physical disabilities or chronic illness; one
member appointed by the mental health association of Minnesota,
in consultation with the Minnesota chapter of the society of
Americans for recovery, to represent consumers with mental
illness or chemical dependency; one appointed under the rules of
the senate; and one appointed under the rules of the house of
representatives.
(f) [EMPLOYEE UNIONS.] The commission includes three
representatives of labor unions, including two appointed by the
AFL-CIO Minnesota and one appointed by the governor to represent
other unions.
(g) [STATE AGENCIES.] The commission includes the
commissioners of commerce, employee relations, and human
services.
(h) [REGIONAL COORDINATING BOARDS.] The commission includes
one member who is the chair of a regional coordinating board,
elected by a majority vote of the chairs of the regional
coordinating boards.
(h) (i) [CHAIR.] The governor shall designate the chair of
the commission from among the governor's appointees.
Sec. 2. Minnesota Statutes 1994, section 62J.05,
subdivision 9, is amended to read:
Subd. 9. [REPEALER.] This section is repealed effective
July 1, 1996 2000.
Sec. 3. Minnesota Statutes 1994, section 62J.09,
subdivision 1, is amended to read:
Subdivision 1. [GENERAL DUTIES.] The regional coordinating
boards are locally controlled boards consisting of providers,
health plan companies, employers, consumers, and elected
officials. Regional coordinating boards may:
(1) recommend that the commissioner approve voluntary
agreements between providers in the region that will improve
quality, access, or affordability of health care but might
constitute a violation of antitrust laws if undertaken without
government direction;
(2) make recommendations to the commissioner regarding
major capital expenditures or the introduction of expensive new
technologies and medical practices that are being proposed or
considered by providers;
(3) undertake voluntary activities to educate consumers,
providers, and purchasers or to promote voluntary, cooperative
community cost containment, access, or quality of care
projects about community plans and projects promoting health
care cost containment, consumer accountability, access, and
quality and efforts to achieve public health goals;
(4) (2) make recommendations to the commissioner regarding
ways of improving affordability, accessibility, and quality of
health care in the region and throughout the state.;
(3) provide technical assistance to parties interested in
establishing or operating a community integrated service network
or integrated service network within the region. This
assistance must complement assistance provided by the
commissioner under section 62N.23;
(4) advise the commissioner on public health goals, taking
into consideration the relevant portions of the community health
service plans, plans required by the Minnesota comprehensive
adult mental health act, the Minnesota comprehensive children's
mental health act, and the community social service act plans
developed by county boards or community health boards in the
region under chapters 145A, 245, and 256E;
(5) prepare an annual regional education plan that is
consistent with and supportive of public health goals identified
by community health boards in the region; and
(6) serve as advisory bodies to identify potential
applicants for federal Health Professional Shortage Area and
federal Medically Underserved Area designation as requested by
the commissioner.
Sec. 4. Minnesota Statutes 1994, section 62J.09,
subdivision 2, is amended to read:
Subd. 2. [MEMBERSHIP.] (a) [NUMBER OF MEMBERS.] Each
regional coordinating board consists of 17 members as provided
in this subdivision. A member may designate a representative to
act as a member of the board in the member's absence. The
governor shall appoint the chair of each regional board from
among its members. The appointing authorities under each
paragraph for which there is to be chosen more than one member
shall consult prior to appointments being made to ensure that,
to the extent possible, the board includes a representative from
each county within the region.
(b) [PROVIDER REPRESENTATIVES.] Each regional board must
include four members representing health care providers who
practice in the region. One member is appointed by the
Minnesota Medical Association. One member is appointed by the
Minnesota Hospital Association. One member is appointed by the
Minnesota Nurses' Association. The remaining member is
appointed by the governor to represent providers other than
physicians, hospitals, and nurses.
(c) [HEALTH PLAN COMPANY REPRESENTATIVES.] Each regional
board includes four members representing health plan companies
who provide coverage for residents of the region, including one
member representing health insurers who is elected by a vote of
all health insurers providing coverage in the region, one member
elected by a vote of all health maintenance organizations
providing coverage in the region, and one member appointed by
Blue Cross and Blue Shield of Minnesota. The fourth member is
appointed by the governor.
(d) [EMPLOYER REPRESENTATIVES.] Regional boards include
three members representing employers in the region. Employer
representatives are appointed by the Minnesota chamber of
commerce from nominations provided by members of chambers of
commerce in the region. At least one member must represent
self-insured employers.
(e) [EMPLOYEE UNIONS.] Regional boards include one member
appointed by the AFL-CIO Minnesota who is a union member
residing or working in the region or who is a representative of
a union that is active in the region.
(f) [PUBLIC MEMBERS.] Regional boards include three
consumer members. One consumer member is elected by the
community health boards in the region, with each community
health board having one vote. One consumer member is elected by
the state legislators with districts in the region legislative
commission on health care access. One consumer member is
appointed by the governor.
(g) [COUNTY COMMISSIONER.] Regional boards include one
member who is a county board member. The county board member is
elected by a vote of all of the county board members in the
region, with each county board having one vote.
(h) [STATE AGENCY.] Regional boards include one state
agency commissioner appointed by the governor to represent state
health coverage programs.
Sec. 5. Minnesota Statutes 1994, section 62J.09, is
amended by adding a subdivision to read:
Subd. 3a. [COMMUNICATION WITH HEALTH CARE COMMISSION.] The
chairs of the regional coordinating boards shall meet with the
chair and the executive director of the health care commission
on a periodic basis, but no less than biennially.
Sec. 6. Minnesota Statutes 1994, section 62J.09,
subdivision 6, is amended to read:
Subd. 6. [TECHNICAL ASSISTANCE.] The commissioner shall
provide technical assistance to regional coordinating
boards. Technical assistance includes providing each regional
board with timely information concerning action plans,
enrollment data, and health care expenditures affecting the
regional board's region.
Sec. 7. Minnesota Statutes 1994, section 62J.09,
subdivision 8, is amended to read:
Subd. 8. [REPEALER.] This section is repealed effective
July 1, 1996 2000.
Sec. 8. Minnesota Statutes 1994, section 62J.17,
subdivision 4a, is amended to read:
Subd. 4a. [EXPENDITURE REPORTING.] (a) [GENERAL
REQUIREMENT.] A provider making a major spending commitment
after April 1, 1992, shall submit notification of the
expenditure to the commissioner and provide the commissioner
with any relevant background information.
(b) [REPORT.] Notification must include a report,
submitted within 60 days after the date of the major spending
commitment, using terms conforming to the definitions in section
62J.03 and this section. Each report is subject to
retrospective review and must contain:
(1) a detailed description of the major spending
commitment, including the specific dollar amount of each
expenditure, and its purpose;
(2) the date of the major spending commitment;
(3) a statement of the expected impact that the major
spending commitment will have on charges by the provider to
patients and third party payers;
(4) a statement of the expected impact on the clinical
effectiveness or quality of care received by the patients that
the provider expects to serve;
(5) a statement of the extent to which equivalent services
or technology are already available to the provider's actual and
potential patient population;
(6) a statement of the distance from which the nearest
equivalent services or technology are already available to the
provider's actual and potential population;
(7) a statement describing the pursuit of any lawful
collaborative arrangements; and
(8) a statement of assurance that the provider will not
use, purchase, or perform health care technologies and
procedures that are not clinically effective and cost-effective,
unless the technology is used for experimental or research
purposes to determine whether a technology or procedure is
clinically effective and cost-effective.
The provider may submit any additional information that it
deems relevant.
(c) [ADDITIONAL INFORMATION.] The commissioner may request
additional information from a provider for the purpose of review
of a report submitted by that provider, and may consider
relevant information from other sources. A provider shall
provide any information requested by the commissioner within the
time period stated in the request, or within 30 days after the
date of the request if the request does not state a time.
(d) [FAILURE TO COMPLY.] If the provider fails to submit a
complete and timely expenditure report, including any additional
information requested by the commissioner, the commissioner may
make the provider's subsequent major spending commitments
subject to the procedures of prospective review and approval
under subdivision 6a.
Sec. 9. Minnesota Statutes 1994, section 62J.17,
subdivision 6a, is amended to read:
Subd. 6a. [PROSPECTIVE REVIEW AND APPROVAL.] (a)
[REQUIREMENT.] No health care provider subject to prospective
review under this subdivision shall make a major spending
commitment unless:
(1) the provider has filed an application with the
commissioner to proceed with the major spending commitment and
has provided all supporting documentation and evidence requested
by the commissioner; and
(2) the commissioner determines, based upon this
documentation and evidence, that the major spending commitment
is appropriate under the criteria provided in subdivision 5a in
light of the alternatives available to the provider.
(b) [APPLICATION.] A provider subject to prospective
review and approval shall submit an application to the
commissioner before proceeding with any major spending
commitment. The application must address each item listed in
subdivision 4a, paragraph (a), and must also include
documentation to support the response to each item. The
provider may submit information, with supporting documentation,
regarding why the major spending commitment should be excepted
from prospective review under paragraph (d) subdivision 7. The
submission may be made either in addition to or instead of the
submission of information relating to the items listed in
subdivision 4a, paragraph (a).
(c) [REVIEW.] The commissioner shall determine, based upon
the information submitted, whether the major spending commitment
is appropriate under the criteria provided in subdivision 5a, or
whether it should be excepted from prospective review
under paragraph (d) subdivision 7. In making this
determination, the commissioner may also consider relevant
information from other sources. At the request of the
commissioner, the Minnesota health care commission shall convene
an expert review panel made up of persons with knowledge and
expertise regarding medical equipment, specialized services,
health care expenditures, and capital expenditures to review
applications and make recommendations to the commissioner. The
commissioner shall make a decision on the application within 60
days after an application is received.
(d) [EXCEPTIONS.] The prospective review and approval
process does not apply to:
(1) a major spending commitment to replace existing
equipment with comparable equipment, if the old equipment will
no longer be used in the state;
(2) a major spending commitment made by a research and
teaching institution for purposes of conducting medical
education, medical research supported or sponsored by a medical
school or by a federal or foundation grant, or clinical trials;
(3) a major spending commitment to repair, remodel, or
replace existing buildings or fixtures if, in the judgment of
the commissioner, the project does not involve a substantial
expansion of service capacity or a substantial change in the
nature of health care services provided; and
(4) mergers, acquisitions, and other changes in ownership
or control that, in the judgment of the commissioner, do not
involve a substantial expansion of service capacity or a
substantial change in the nature of health care services
provided.
(e) [NOTIFICATION REQUIRED FOR EXCEPTED MAJOR SPENDING
COMMITMENT.] A provider making a major spending commitment
covered by paragraph (d) shall provide notification of the major
spending commitment as provided under subdivision 4a.
(f) (d) [PENALTIES AND REMEDIES.] The commissioner of
health has the authority to issue fines, seek injunctions, and
pursue other remedies as provided by law.
Sec. 10. Minnesota Statutes 1994, section 62J.17, is
amended by adding a subdivision to read:
Subd. 7. [EXCEPTIONS.] (a) The retrospective review
process as described in subdivision 5a and the prospective
review and approval process as described in subdivision 6a do
not apply to:
(1) a major spending commitment to replace existing
equipment with comparable equipment used for direct patient
care, upgrades of equipment beyond the current model, or
comparable model must be reported;
(2) a major spending commitment made by a research and
teaching institution for purposes of conducting medical
education, medical research supported or sponsored by a medical
school, or by a federal or foundation grant or clinical trials;
(3) a major spending commitment to repair, remodel, or
replace existing buildings or fixtures if, in the judgment of
the commissioner, the project does not involve a substantial
expansion of service capacity or a substantial change in the
nature of health care services provided;
(4) a major spending commitment for building maintenance
including heating, water, electricity, and other
maintenance-related expenditures;
(5) a major spending commitment for activities, not
directly related to the delivery of patient care services,
including food service, laundry, housekeeping, and other
service-related activities; and
(6) a major spending commitment for computer equipment or
data systems not directly related to the delivery of patient
care services, including computer equipment or data systems
related to medical record automation.
(b) In addition to the exceptions listed in subdivision 7,
paragraph (a), the prospective review and approval process
described in subdivision 6a does not apply to mergers,
acquisitions, and other changes in ownership or control that, in
the judgment of the commissioner, do not involve a substantial
expansion of service capacity or a substantial change in the
nature of health care services provided.
Sec. 11. Minnesota Statutes 1994, section 62J.48, is
amended to read:
62J.48 [CRITERIA FOR REIMBURSEMENT.]
All ambulance services licensed under section 144.802 are
eligible for reimbursement under the integrated service network
system and the regulated all-payer option health plan companies.
The commissioner shall require community integrated service
networks, integrated service networks, and all-payer
insurers health plan companies to adopt the following
reimbursement policies.
(1) All scheduled or prearranged air and ground ambulance
transports must be reimbursed if requested by an attending
physician or nurse, and, if the person is an enrollee in an
integrated service network or community integrated service
network a health plan company, if approved by a designated
representative of an integrated service network or a community
service network a health plan company who is immediately
available on a 24-hour basis. The designated representative
must be a registered nurse or a physician assistant with at
least three years of critical care or trauma experience, or a
licensed physician.
(2) Reimbursement must be provided for all emergency
ambulance calls in which a patient is transported or medical
treatment rendered.
(3) Special transportation services must not be billed or
reimbursed if the patient needs medical attention immediately
before transportation.
Sec. 12. Minnesota Statutes 1994, section 62M.07, is
amended to read:
62M.07 [PRIOR AUTHORIZATION OF SERVICES.]
(a) 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 72A.201, subdivision 4a,
regarding time frames for approving and disapproving prior
authorization requests;
(4) written procedures for appeals of denials of prior
authorization which specify the responsibilities of the enrollee
and provider, and which meet the requirements of section
72A.285, regarding release of summary review findings; and
(5) procedures to ensure confidentiality of
patient-specific information, consistent with applicable law.
(b) No utilization review organization, health plan
company, or claims administrator may conduct or require prior
authorization of emergency confinement or emergency treatment.
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 after
the beginning of the emergency confinement or emergency
treatment as reasonably possible.
Sec. 13. Minnesota Statutes 1994, 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 in compliance with section
62M.07, paragraph (c). 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 certification request. The utilization
review organization must have a procedure for ensuring, at a
minimum, the periodic annual evaluation and updating of the
written criteria based on sound clinical principles.
Sec. 14. Minnesota Statutes 1994, section 62M.10, is
amended by adding a subdivision to read:
Subd. 7. [AVAILABILITY OF CRITERIA.] Upon request, a
utilization review organization shall provide to an enrollee or
to an attending physician or provider the criteria used for a
specific procedure to determine the necessity, appropriateness,
and efficacy of that procedure and identify the database,
professional treatment guideline, or other basis for the
criteria.
Sec. 15. Minnesota Statutes 1994, section 62P.05,
subdivision 4, is amended to read:
Subd. 4. [MONITORING AND ENFORCEMENT.] Health care
providers shall submit to the commissioner of health, in the
form and at the times required by the commissioner, all
information the commissioner determines to be necessary to
implement and enforce this section. The commissioner shall
regularly audit all health clinics employing or contracting with
over 100 physicians. The commissioner shall also audit, at
times and in a manner that does not interfere with delivery of
patient care, a sample of smaller clinics and other health care
providers. Providers that exceed revenue limits based on
two-year average revenue data shall be required by the
commissioner to pay back the amount exceeding the revenue limits
during the following calendar year.
Pharmacists may adjust their revenue figures for increases
in drug product costs that are set by the manufacturer. The
commissioner shall consult with pharmacy groups, including
pharmacies, wholesalers, drug manufacturers, health plans, and
other interested parties, to determine the methodology for
measuring and implementing the interim growth limits while
taking into account the adjustments for drug product costs.
The commissioner shall monitor providers meeting the growth
limits based on their current fees on an annual basis. The fee
charged for each service must be based on a weighted average
across 12 months and compared to the weighted average for the
previous 12-month period. The percentage increase in the
average fee from 1993 to 1994, and from 1994 to 1995, from 1995
to 1996, and from 1996 to 1997 is subject to the growth limits
established under section 62J.04, subdivision 1, paragraph (b).
The percentage increase in the average fee from 1995 to 1996,
and from 1996 to 1997 is subject to the change in the regional
consumer price index for urban consumers for the previous year
published in the State Register in January of the year that the
growth limit is in effect. The audit process may include a
review of the provider's monthly fee schedule, and a random
claims analysis for the provider during different parts of the
year to monitor variations in fees. The commissioner shall
require providers that exceed growth limits, based on annual
fees, to pay back during the following calendar year the amount
of fees received exceeding the limit.
The commissioner shall notify each provider that has
exceeded its revenue or fee limit, at least 30 days before
taking action, and shall provide each provider with ten days to
provide an explanation for exceeding the revenue or fee limit.
The commissioner shall review the explanation and may change a
determination if the commissioner determines the explanation to
be valid.
The commissioner may approve a different repayment schedule
for a health care provider that takes into account the
provider's financial condition.
A provider may appeal the commissioner's order to pay back
the amount exceeding the revenue or fee limit by mailing a
written notice of appeal to the commissioner within 30 days
after the commissioner's order was mailed. The contested case
and judicial review provisions of chapter 14 apply to the
appeal. The provider shall pay the amount specified by the
commissioner either to the commissioner or into an escrow
account until final resolution of the appeal. Notwithstanding
sections 3.762 to 3.765, each party is responsible for its own
fees and expenses, including attorneys fees, for the appeal.
Any amount required to be paid back under this section shall be
deposited in the health care access fund.
Sec. 16. Minnesota Statutes 1994, section 62P.05, is
amended by adding a subdivision to read:
Subd. 5. [SMALL RURAL HOSPITALS.] Each small rural
hospital shall file information with the commissioner of health
and calculate its growth in revenues pursuant to the
requirements of this chapter. Small rural hospitals that do not
file as part of a hospital system are exempt from the repayment
provisions of subdivision 4. However, the commissioner retains
the authority to initiate an investigation and order repayment
pursuant to this section, if the commissioner believes that
there is an unreasonable rate of growth in revenues and if the
hospital fails to demonstrate good cause for exceeding the
statutory growth limits. For purposes of this subdivision,
small rural hospital is defined as a hospital with less than 50
licensed beds.
Sec. 17. Minnesota Statutes 1994, section 62Q.075,
subdivision 4, is amended to read:
Subd. 4. [REVIEW.] Upon receipt of the plan, the
appropriate commissioner shall provide a copy to the regional
coordinating boards, local community health boards, and other
relevant community organizations within the managed care
organization's service area. After reviewing the plan, these
community groups may submit written comments on the plan to
either the commissioner of health or commerce, as applicable,
and may advise the commissioner of the managed care
organization's effectiveness in assisting to achieve regional
public health goals. The plan may be reviewed by the county
boards, or city councils acting as a local board of health in
accordance with chapter 145A, within the managed care
organization's service area to determine whether the plan is
consistent with the goals and objectives of the plans required
under chapters 145A and 256E and whether the plan meets the
needs of the community. The county board, or applicable city
council, may also review and make recommendations on the
availability and accessibility of services provided by the
managed care organization. The county board, or applicable city
council, may submit written comments to the appropriate
commissioner, and may advise the commissioner of the managed
care organization's effectiveness in assisting to meet the needs
and goals as defined under the responsibilities of chapters 145A
and 256E. The commissioner of health shall develop
recommendations to utilize the written comments submitted as
part of the licensure process to ensure local public
accountability. These recommendations shall be reported to the
legislative commission on health care access by January 15,
1996. Copies of these written comments must be provided to the
managed care organization. The plan and any comments submitted
must be filed with the information clearinghouse to be
distributed to the public.
Sec. 18. Minnesota Statutes 1994, section 62Q.32, is
amended to read:
62Q.32 [LOCAL OMBUDSPERSON.]
County board or community health service agencies may
establish an office of ombudsperson to provide a system of
consumer advocacy for persons receiving health care services
through a health plan company. The ombudsperson's functions may
include, but are not limited to:
(a) mediation or advocacy on behalf of a person accessing
the complaint and appeal procedures to ensure that necessary
medical services are provided by the health plan company; and
(b) investigation of the quality of services provided to a
person and determine the extent to which quality assurance
mechanisms are needed or any other system change may be needed.
The commissioner of health shall make recommendations for
funding these functions including the amount of funding needed
and a plan for distribution. The commissioner shall submit
these recommendations to the legislative commission on health
care access by January 15, 1996.
Sec. 19. Minnesota Statutes 1994, section 62Q.33,
subdivision 4, is amended to read:
Subd. 4. [CAPACITY BUILDING, ACCOUNTABILITY AND FUNDING.]
The recommendations required by subdivision 2 shall include:
(1) a definition of minimum outcomes for implementing core
public health functions, including a local ombudsperson under
the assurance of services function;
(2) the identification of counties and applicable cities
with public health programs that need additional assistance to
meet the minimum outcomes;
(3) a budget for supporting all functions needed to achieve
the minimum outcomes, including the local ombudsperson assurance
of services function;
(4) an analysis of the costs and benefits expected from
achieving the minimum outcomes;
(5) strategies for improving local government public health
functions throughout the state to meet the minimum outcomes
including: (i) funding distribution for local government public
health functions necessary to meet the minimum outcomes; and (ii)
strategies for the financing of personal health care services
within the uniform benefits set through the health plan
companies and identifying appropriate mechanisms for the
delivery of these services; and
(6) a recommended level of dedicated funding for local
government public health functions in terms of a percentage of
total health service expenditures by the state or in terms of a
per capita basis, including methods of allocating the dedicated
funds to local government. Funding recommendations must be
broad-based and must consider all financial resources.
Sec. 20. Minnesota Statutes 1994, section 62Q.33,
subdivision 5, is amended to read:
Subd. 5. [TIMELINE.] (a) By October 1, 1994, the
commissioner shall submit to the legislative commission on
health care access the initial report and recommendations
required by subdivisions 2 to 4.
(b) By February January 15, 1995 1996, the
commissioner, in cooperation with the legislative commission on
health care access, shall submit a final report to the
legislature, with specific recommendations for capacity building
and financing to be implemented over the period from January 1,
1996, through December 31, 1997.
(c) (b) By January 1 15, 1997, and by January 1 15 of
each odd-numbered year thereafter, the commissioner shall
present to the legislature an updated report and recommendations.
Sec. 21. Minnesota Statutes 1994, section 72A.20, is
amended by adding a subdivision to read:
Subd. 32. [UNFAIR HEALTH RISK AVOIDANCE.] No insurer or
health plan company may design a network of providers, policies
on access to providers, or marketing strategy in such a way as
to discourage enrollment by individuals or groups whose health
care needs are perceived as likely to be more expensive than the
average. This subdivision does not prohibit underwriting and
rating practices that comply with Minnesota law.
Sec. 22. Minnesota Statutes 1994, section 72A.20, is
amended by adding a subdivision to read:
Subd. 33. [PROHIBITION OF INAPPROPRIATE INCENTIVES.] No
insurer or health plan company may give any financial incentive
to a health care provider based solely on the number of services
denied or referrals not authorized by the provider. This
subdivision does not prohibit capitation or other compensation
methods that serve to hold health care providers financially
accountable for the cost of caring for a patient population.
Sec. 23. Minnesota Statutes 1994, section 136A.1355,
subdivision 3, is amended to read:
Subd. 3. [LOAN FORGIVENESS.] For the period July 1, 1993
through June 30, 1995 fiscal years beginning on and after July
1, 1995, the higher education coordinating board may accept up
to four applicants who are fourth year medical students, three
applicants who are pediatric residents, and four applicants who
are family practice residents, and one applicant who is an
internal medicine resident, per fiscal year for participation in
the loan forgiveness program. If the higher education
coordinating board does not receive enough applicants per fiscal
year to fill the number of residents in the specific areas of
practice, the resident applicants may be from any area of
practice. The eight resident applicants can may be in any year
of training; however, priority must be given to the following
categories of residents in descending order: third year
residents, second year residents, and first year residents.
Applicants are responsible for securing their own loans.
Applicants chosen to participate in the loan forgiveness program
may designate for each year of medical school, up to a maximum
of four years, an agreed amount, not to exceed $10,000, as a
qualified loan. For each year that a participant serves as a
physician in a designated rural area, up to a maximum of four
years, the higher education coordinating board shall annually
pay an amount equal to one year of qualified loans.
Participants who move their practice from one designated rural
area to another remain eligible for loan repayment. In
addition, if a resident participating in the loan forgiveness
program serves at least four weeks during a year of residency
substituting for a rural physician to temporarily relieve the
rural physician of rural practice commitments to enable the
rural physician to take a vacation, engage in activities outside
the practice area, or otherwise be relieved of rural practice
commitments, the participating resident may designate up to an
additional $2,000, above the $10,000 maximum, for each year of
residency during which the resident substitutes for a rural
physician for four or more weeks.
Sec. 24. Minnesota Statutes 1994, section 136A.1355,
subdivision 5, is amended to read:
Subd. 5. [LOAN FORGIVENESS; UNDERSERVED URBAN
COMMUNITIES.] For the period July 1, 1993 to June 30,
1995 fiscal years beginning on and after July 1, 1995, the
higher education coordinating board may accept up to four
applicants who are either fourth year medical students, or
residents in family practice, pediatrics, or internal medicine
per fiscal year for participation in the urban primary care
physician loan forgiveness program. The resident applicants may
be in any year of residency training; however, priority will be
given to the following categories of residents in descending
order: third year residents, second year residents, and first
year residents. If the higher education coordinating board does
not receive enough qualified applicants per fiscal year to fill
the number of slots for urban underserved communities, the slots
may be allocated to students or residents who have applied for
the rural physician loan forgiveness program in subdivision 1.
Applicants are responsible for securing their own loans. For
purposes of this provision, "qualifying educational loans" are
government and commercial loans for actual costs paid for
tuition, reasonable education expenses, and reasonable living
expenses related to the graduate or undergraduate education of a
health care professional. Applicants chosen to participate in
the loan forgiveness program may designate for each year of
medical school, up to a maximum of four years, an agreed amount,
not to exceed $10,000, as a qualified loan. For each year that
a participant serves as a physician in a designated underserved
urban area, up to a maximum of four years, the higher education
coordinating board shall annually pay an amount equal to one
year of qualified loans. Participants who move their practice
from one designated underserved urban community to another
remain eligible for loan repayment.
Sec. 25. Minnesota Statutes 1994, section 136A.1356,
subdivision 3, is amended to read:
Subd. 3. [ELIGIBILITY.] To be eligible to participate in
the program, a prospective midlevel practitioner must submit a
letter of interest to the higher education coordinating board
prior to or while attending a program of study designed to
prepare the individual for service as a midlevel practitioner.
Before completing the first year of this program, A midlevel
practitioner student who is accepted into this program must sign
a contract to agree to serve at least two of the first four
years following graduation from the program in a designated
rural area.
Sec. 26. Minnesota Statutes 1994, section 136A.1356,
subdivision 4, is amended to read:
Subd. 4. [LOAN FORGIVENESS.] The higher education
coordinating board may accept up to eight applicants per year
for participation in the loan forgiveness program. Applicants
are responsible for securing their own loans. Applicants chosen
to participate in the loan forgiveness program may designate for
each year of midlevel practitioner study, up to a maximum of two
years, an agreed amount, not to exceed $7,000, as a qualified
loan. For purposes of this provision, "qualifying educational
loans" are government and commercial loans for actual costs paid
for tuition, reasonable education expenses, and reasonable
living expenses related to the graduate or undergraduate
education of a health care professional. For each year that a
participant serves as a midlevel practitioner in a designated
rural area, up to a maximum of four years, the higher education
coordinating board shall annually repay an amount equal to
one-half a qualified loan. Participants who move their practice
from one designated rural area to another remain eligible for
loan repayment.
Sec. 27. [137.42] [GRANTS FOR AREA HEALTH EDUCATION CENTER
PROGRAMS.]
Subdivision 1. [GRANT APPLICATION.] The board of regents
of the University of Minnesota, through the academic health
center and the University of Minnesota-Duluth School of
Medicine, is requested to apply for a federal Area Health
Education Center Program grant. If awarded a grant, the
University of Minnesota-Duluth School of Medicine, in
cooperation with public or private, nonprofit area health
education centers, is requested to plan, develop, and operate
area health education center programs. The University of
Minnesota-Duluth School of Medicine is requested to develop
cooperative arrangements with two area health education centers
in year two of the grant, and develop cooperative arrangements
with an additional two centers in year three of the grant.
Subd. 2. [PROGRAM REQUIREMENTS.] Each program must:
(1) provide preceptorship educational experiences for
health science students;
(2) maintain community-based primary care residency
programs or be affiliated with such programs;
(3) maintain continuing education programs for health
professionals or coordinate its activities with such programs;
(4) maintain learning resources and dissemination systems;
(5) have agreements with community-based organizations for
educating and training health professionals;
(6) train health professionals, including nurses and allied
health professionals; and
(7) carry out recruitment and health career awareness
programs among minority and other students in medically
underserved areas of the state.
Sec. 28. [137.43] [SUBSTITUTE PHYSICIAN DEMONSTRATION
PROJECT.]
Subdivision 1. [ESTABLISHMENT.] The board of regents,
through the University of Minnesota academic health center, is
requested to establish and administer a substitute physician
(locum tenens and emergency room coverage) demonstration project
at up to four rural demonstration sites within the state. The
academic health center is requested to coordinate the
administration of the project with the commissioner of health
and the office of rural health and primary health care.
Subd. 2. [PROJECT ACTIVITIES.] The project must:
(1) encourage physicians to serve as substitute physicians
for the demonstration sites;
(2) provide a central register of physicians interested in
serving as substitute physicians at the demonstration sites;
(3) provide a referral service for requests from
demonstration sites for substitute physicians; and
(4) provide substitute physician services at rates that
reflect the administrative savings resulting from centralized
referral and credentialing.
Subd. 3. [CREDENTIALING; PROFESSIONAL EDUCATION.] The
academic health center is requested to credential persons
desiring to serve as substitute physicians. The academic health
center may employ substitute physicians serving in the
demonstration project as temporary clinical faculty and may
provide substitute physicians with additional opportunities for
professional education and interaction.
Subd. 4. [DEMONSTRATION SITES.] The academic health center
is requested to designate up to four rural communities as
demonstration sites for the project. The academic health center
is requested to choose sites based on a community's need for
substitute physician services and the willingness of the
community to work cooperatively with the academic health center
and participate in the demonstration project evaluation.
Sec. 29. Minnesota Statutes 1994, section 144.1464,
subdivision 2, is amended to read:
Subd. 2. [CRITERIA.] (a) The commissioner, through the
organization under contract, shall award grants to hospitals and
clinics that agree to:
(1) provide secondary and post-secondary summer health care
interns with formal exposure to the health care profession;
(2) provide an orientation for the secondary and
post-secondary summer health care interns;
(3) pay one-half the costs of employing the secondary and
post-secondary summer health care intern, based on an overall
hourly wage that is at least the minimum wage but does not
exceed $6 an hour; and
(4) interview and hire secondary and post-secondary pupils
for a minimum of six weeks and a maximum of 12 weeks; and
(5) employ at least one secondary student for each
post-secondary student employed, to the extent that there are
sufficient qualifying secondary student applicants.
(b) In order to be eligible to be hired as a secondary
summer health intern by a hospital or clinic, a pupil must:
(1) intend to complete high school graduation requirements
and be between the junior and senior year of high school;
(2) be from a school district in proximity to the facility;
and
(3) provide the facility with a letter of recommendation
from a health occupations or science educator.
(c) In order to be eligible to be hired as a post-secondary
summer health care intern by a hospital or clinic, a pupil must:
(1) intend to complete a two-year or four-year degree
program and be planning on enrolling in or be enrolled in that
degree program;
(2) be enrolled in a Minnesota educational institution or
be a resident of the state of Minnesota; priority must be given
to applicants from a school district or attend an educational
institution in proximity to the facility; and
(3) provide the facility with a letter of recommendation
from a health occupations or science educator.
(d) Hospitals and clinics awarded grants may employ pupils
as secondary and post-secondary summer health care interns
beginning on or after June 15, 1993, if they agree to pay the
intern, during the period before disbursement of state grant
money, with money designated as the facility's 50 percent
contribution towards internship costs.
Sec. 30. Minnesota Statutes 1994, section 144.1464,
subdivision 3, is amended to read:
Subd. 3. [GRANTS.] The commissioner, through the
organization under contract, shall award separate grants to
hospitals and clinics meeting the requirements of subdivision
2. The grants must be used to pay one-half of the costs of
employing secondary and post-secondary pupils in a hospital or
clinic during the course of the program. No more than 50
percent of the participants may be post-secondary students,
unless the program does not receive enough qualified secondary
applicants per fiscal year. No more than five pupils may be
selected from any secondary or post-secondary institution to
participate in the program and no more than one-half of the
number of pupils selected may be from the seven-county
metropolitan area.
Sec. 31. Minnesota Statutes 1994, section 144.1464,
subdivision 4, is amended to read:
Subd. 4. [CONTRACT.] The commissioner shall contract with
a statewide, nonprofit organization representing facilities at
which secondary and post-secondary summer health care interns
will serve, to administer the grant program established by this
section. Grant funds that are not used in one fiscal year may
be carried over to the next fiscal year. The organization
awarded the grant shall provide the commissioner with any
information needed by the commissioner to evaluate the program,
in the form and at the times specified by the commissioner.
Sec. 32. Minnesota Statutes 1994, section 144.147,
subdivision 1, is amended to read:
Subdivision 1. [DEFINITION.] "Eligible rural hospital"
means any nonfederal, general acute care hospital that:
(1) is either located in a rural area, as defined in the
federal Medicare regulations, Code of Federal Regulations, title
42, section 405.1041, or located in a community with a
population of less than 5,000, according to United States Census
Bureau statistics, outside the seven-county metropolitan area;
(2) has 100 or fewer beds;
(3) is not for profit; and
(4) has not been awarded a grant under the federal rural
health transition grant program, which would be received
concurrently with any portion of the grant period for this
program.
Sec. 33. Minnesota Statutes 1994, section 144.1484,
subdivision 1, is amended to read:
Subdivision 1. [SOLE COMMUNITY HOSPITAL FINANCIAL
ASSISTANCE GRANTS.] The commissioner of health shall award
financial assistance grants to rural hospitals in isolated areas
of the state. To qualify for a grant, a hospital must: (1) be
eligible to be classified as a sole community hospital according
to the criteria in Code of Federal Regulations, title 42,
section 412.92 or be located in a community with a population of
less than 5,000 and located more than 25 miles from a like
hospital currently providing acute short-term services; (2) have
experienced net income losses in the two most recent consecutive
hospital fiscal years for which audited financial information is
available; (3) consist of 40 or fewer licensed beds; and (4)
demonstrate to the commissioner that it has obtained local
support for the hospital and that any state support awarded
under this program will not be used to supplant local support
for the hospital. The commissioner shall review audited
financial statements of the hospital to assess the extent of
local support. Evidence of local support may include bonds
issued by a local government entity such as a city, county, or
hospital district for the purpose of financing hospital
projects; and loans, grants, or donations to the hospital from
local government entities, private organizations, or
individuals. The commissioner shall determine the amount of the
award to be given to each eligible hospital based on the
hospital's financial need operating loss margin (total operating
losses as a percentage of total operating revenue) for the two
most recent consecutive fiscal years for which audited financial
information is available and the total amount of funding
available. One hundred percent of the available funds will be
disbursed proportionately based on the operating loss margins of
the eligible hospitals.
Sec. 34. Minnesota Statutes 1994, section 144.1486,
subdivision 4, is amended to read:
Subd. 4. [ELIGIBILITY REQUIREMENTS.] In order to qualify
for community health center program funding, a project must:
(1) be located in a rural shortage area that is a medically
underserved, federal health professional shortage, or governor
designated shortage area. "Rural" means an area of the state
outside the ten-county seven-county Twin Cities metropolitan
area and outside of the Duluth, St. Cloud, East Grand Forks,
Moorhead, Rochester, and LaCrosse census defined urbanized
areas;
(2) represent or propose the formation of a nonprofit
corporation with local resident governance, or be a governmental
entity. Applicants in the process of forming a nonprofit
corporation may have a nonprofit coapplicant serve as financial
agent through the remainder of the formation period. With the
exception of governmental entities, all applicants must submit
application for nonprofit incorporation and 501(c)(3) tax-exempt
status within six months of accepting community health center
grant funds;
(3) result in a locally owned and operated community health
center that provides primary and preventive health care
services, and incorporates quality assurance, regular reviews of
clinical performance, and peer review;
(4) seek to employ midlevel professionals, where
appropriate;
(5) demonstrate community and popular support and provide a
20 percent local match of state funding; and
(6) propose to serve an area that is not currently
served or was not served prior to establishment of a
state-funded community health center by a federally certified
medical organization.
Sec. 35. Minnesota Statutes 1994, section 144.1487,
subdivision 1, is amended to read:
Subdivision 1. [DEFINITIONS.] (a) For purposes of sections
144.1487 to 144.1492, the following definitions apply definition
applies.
(b) "Board" means the higher education coordinating board.
(c) "Health professional shortage area" means an area
designated as such by the federal Secretary of Health and Human
Services, as provided under Code of Federal Regulations, title
42, part 5, and United States Code, title 42, section 254E.
Sec. 36. Minnesota Statutes 1994, section 144.1488,
subdivision 1, is amended to read:
Subdivision 1. [DUTIES OF THE COMMISSIONER OF HEALTH.] The
commissioner shall administer the state loan repayment program.
The commissioner shall:
(1) ensure that federal funds are used in accordance with
program requirements established by the federal National Health
Services Corps;
(2) notify potentially eligible loan repayment sites about
the program;
(3) develop and disseminate application materials to sites;
(4) review and rank applications using the scoring criteria
approved by the federal Department of Health and Human Services
as part of the Minnesota department of health's National Health
Services Corps state loan repayment program application;
(5) select sites that qualify for loan repayment based upon
the availability of federal and state funding;
(6) provide the higher education coordinating board with a
list of qualifying sites; and
(7) carry out other activities necessary to implement and
administer sections 144.1487 to 144.1492.;
The commissioner shall enter into an interagency agreement
with the higher education coordinating board to carry out the
duties assigned to the board under sections 144.1487 to 144.1492.
(7) verify the eligibility of program participants;
(8) sign a contract with each participant that specifies
the obligations of the participant and the state;
(9) arrange for the payment of qualifying educational loans
for program participants;
(10) monitor the obligated service of program participants;
(11) waive or suspend service or payment obligations of
participants in appropriate situations;
(12) place participants who fail to meet their obligations
in default; and
(13) enforce penalties for default.
Sec. 37. Minnesota Statutes 1994, section 144.1488,
subdivision 4, is amended to read:
Subd. 4. [ELIGIBLE HEALTH PROFESSIONALS.] (a) To be
eligible to apply to the higher education coordinating board
commissioner for the loan repayment program, health
professionals must be citizens or nationals of the United
States, must not have any unserved obligations for service to a
federal, state, or local government, or other entity, and must
be ready to begin full-time clinical practice upon signing a
contract for obligated service.
(b) In selecting physicians for participation, the board
commissioner shall give priority to physicians who are board
certified or have completed a residency in family practice,
osteopathic general practice, obstetrics and gynecology,
internal medicine, or pediatrics. A physician selected for
participation is not eligible for loan repayment until the
physician has an employment agreement or contract with an
eligible loan repayment site and has signed a contract for
obligated service with the higher education coordinating
board commissioner.
Sec. 38. Minnesota Statutes 1994, section 144.1489,
subdivision 1, is amended to read:
Subdivision 1. [CONTRACT REQUIRED.] Before starting the
period of obligated service, a participant must sign a contract
with the higher education coordinating board commissioner that
specifies the obligations of the participant and the board
commissioner.
Sec. 39. Minnesota Statutes 1994, section 144.1489,
subdivision 3, is amended to read:
Subd. 3. [LENGTH OF SERVICE.] Participants must agree to
provide obligated service for a minimum of two years. A
participant may extend a contract to provide obligated service
for a third and fourth year, subject to board approval and the
availability of federal and state funding.
Sec. 40. Minnesota Statutes 1994, section 144.1489,
subdivision 4, is amended to read:
Subd. 4. [AFFIDAVIT OF SERVICE REQUIRED.] Within 30 days
of the start of obligated service, and by February 1 of each
succeeding calendar year, a participant shall submit an
affidavit to the board commissioner stating that the participant
is providing the obligated service and which is signed by a
representative of the organizational entity in which the service
is provided. Participants must provide written notice to
the board commissioner within 30 days of: a change in name or
address, a decision not to fulfill a service obligation, or
cessation of clinical practice.
Sec. 41. Minnesota Statutes 1994, section 144.1490, is
amended to read:
144.1490 [RESPONSIBILITIES OF THE LOAN REPAYMENT PROGRAM.]
Subdivision 1. [LOAN REPAYMENT.] Subject to the
availability of federal and state funds for the loan repayment
program, the higher education coordinating board commissioner
shall pay all or part of the qualifying education loans up to
$20,000 annually for each primary care physician participant
that fulfills the required service obligation. For purposes of
this provision, "qualifying educational loans" are government
and commercial loans for actual costs paid for tuition,
reasonable education expenses, and reasonable living expenses
related to the graduate or undergraduate education of a health
care professional.
Subd. 2. [PROCEDURE FOR LOAN REPAYMENT.] Program
participants, at the time of signing a contract, shall designate
the qualifying loan or loans for which the higher education
coordinating board commissioner is to make payments. The
participant shall submit to the board commissioner all payment
books for the designated loan or loans or all monthly billings
for the designated loan or loans within five days of receipt.
The board commissioner shall make payments in accordance with
the terms and conditions of the designated loans, in an amount
not to exceed $20,000 when annualized. If the amount paid by
the board commissioner is less than $20,000 during a 12-month
period, the board commissioner shall pay during the 12th month
an additional amount towards a loan or loans designated by the
participant, to bring the total paid to $20,000. The total
amount paid by the board commissioner must not exceed the amount
of principal and accrued interest of the designated loans.
Sec. 42. Minnesota Statutes 1994, section 144.1491,
subdivision 2, is amended to read:
Subd. 2. [SUSPENSION OR WAIVER OF OBLIGATION.] Payment or
service obligations cancel in the event of a participant's
death. The board commissioner may waive or suspend payment or
service obligations in case of total and permanent disability or
long-term temporary disability lasting for more than two years.
The board commissioner shall evaluate all other requests for
suspension or waivers on a case-by-case basis.
Sec. 43. [144.1493] [NURSING GRANT PROGRAM.]
Subdivision 1. [ESTABLISHMENT.] A nursing grant program is
established under the supervision of the commissioner of health
and the administration of the metropolitan healthcare
foundation's project LINC to provide grants to Minnesota health
care facility employees seeking to complete a baccalaureate or
master's degree in nursing.
Subd. 2. [RESPONSIBILITY OF METROPOLITAN HEALTHCARE
FOUNDATION'S PROJECT LINC.] The metropolitan healthcare
foundation's project LINC shall administer the grant program and
award grants to eligible health care facility employees. To be
eligible to receive a grant, a person must be:
(1) an employee of a health care facility located in
Minnesota, whom the facility has recommended to the metropolitan
healthcare foundation's project LINC for consideration;
(2) working part time, up to 32 hours per pay period, for
the health care facility, while maintaining full salary and
benefits;
(3) enrolled full time in a Minnesota school or college of
nursing to complete a baccalaureate or master's degree in
nursing; and
(4) a resident of the state of Minnesota.
The grant must be awarded for one academic year but is
renewable for a maximum of six semesters or nine quarters of
full-time study, or their equivalent. The grant must be used
for tuition, fees, and books. Priority in awarding grants shall
be given to persons with the greatest financial need. The
health care facility may require its employee to commit to a
reasonable postprogram completion of employment at the health
care facility as a condition for the financial support the
facility provides.
Subd. 3. [RESPONSIBILITY OF COMMISSIONER.] The
commissioner shall distribute money each year to the
metropolitan healthcare foundation's project LINC to be used to
award grants under this section, provided that the commissioner
shall not distribute the money unless the metropolitan
healthcare foundation's project LINC matches the money with an
equal amount from nonstate sources. The metropolitan healthcare
foundation's project LINC shall expend nonstate money prior to
expending state money and shall return to the commissioner all
state money not used each year for nursing program grants to be
redistributed under this section. The metropolitan healthcare
foundation's project LINC shall report to the commissioner on
its program activity as requested by the commissioner.
Sec. 44. Minnesota Statutes 1994, section 144.801, is
amended by adding a subdivision to read:
Subd. 11. [FIRST RESPONDER.] "First responder" means an
individual who is certified by the commissioner to perform, at a
minimum, basic emergency skills before the arrival of a licensed
ambulance service, and is:
(1) a member of an organized service recognized by a local
political subdivision whose primary responsibility is to respond
to medical emergencies to provide initial medical care before
the arrival of a licensed ambulance service; or
(2) a member of an organized industrial medical first
response team.
Sec. 45. Minnesota Statutes 1994, section 144.804,
subdivision 1, is amended to read:
Subdivision 1. [DRIVERS AND ATTENDANTS.] No publicly or
privately owned basic ambulance service shall be operated in the
state unless its drivers and attendants possess a current
emergency care course certificate authorized by rules adopted by
the commissioner of health according to chapter 14. Until
August 1, 1994 1997, a licensee may substitute a person
currently certified by the American Red Cross in advanced first
aid and emergency care or a person who has successfully
completed the United States Department of Transportation first
responder curriculum, and who has also been trained to use basic
life support equipment as required by rules adopted by the
commissioner under section 144.804, subdivision 3, for one of
the persons on a basic ambulance, provided that person will
function as the driver while transporting a patient. The
commissioner may grant a variance to allow a licensed ambulance
service to use attendants certified by the American Red Cross in
advanced first aid and emergency care and, until August 1, 1997,
to use attendants who have successfully completed the United
States Department of Transportation first responder curriculum,
and who have been trained to use basic life support equipment as
required by rules adopted by the commissioner under subdivision
3, in order to ensure 24-hour emergency ambulance coverage. The
commissioner shall study the roles and responsibilities of first
responder units and report the findings by January 1, 1991.
This study shall address at a minimum:
(1) education and training;
(2) appropriate equipment and its use;
(3) medical direction and supervision; and
(4) supervisory and regulatory requirements.
Sec. 46. Minnesota Statutes 1994, section 148B.32,
subdivision 1, is amended to read:
Subdivision 1. [UNLICENSED PRACTICE PROHIBITED.] After
adoption of rules by the board implementing sections 148B.29 to
148B.39, no individual shall engage in marriage and family
therapy practice unless that individual holds a valid license
issued under sections 148B.29 to 148B.39.
Marriage and family therapy practice is not medical care
nor any other type of remedial care that may be reimbursed under
medical assistance, chapter 256B, except to the extent such care
is reimbursed under section 256B.0625, subdivision 5. Marriage
and family therapists may not be reimbursed under medical
assistance, chapter 256B, except to the extent such care is
reimbursed under section 256B.0625, subdivision 5, or when
marriage and family therapists are employed by a managed care
organization with a contract to provide mental health care to
medical assistance enrollees, and are reimbursed through the
managed care organization.
Sec. 47. Laws 1993, chapter 224, article 4, section 40, is
amended to read:
Sec. 40. [INTEGRATED CHILDREN'S DATABASE.]
Subdivision 1. [PLAN.] The departments of education,
administration, health and human services, and the office of
strategic and long-range planning shall jointly develop a plan
for an integrated statewide children's service database. The
plan must contain common essential data elements that include
all children from birth through kindergarten enrollment by July
1, 1995. The essential data elements shall be the basis for a
statewide children's service database. Initial service areas
shall include but are not limited to: early childhood and
family education, ECFE tribal schools, children with special
health care needs, learning readiness, way to grow, early
childhood special education part H, even start, school health,
home visitor, lead poisoning screening, child care resources and
referral, child care service development, child trust fund,
migrant child care, dependent child care, headstart and
community resource program.
In developing a plan for a statewide integrated children's
database the joint planning team must:
(1) conduct a high-level needs analysis of service delivery
and reporting and decision making areas;
(2) catalogue current information systems;
(3) establish outcomes for developing systems;
(4) analyze the needs of individuals and organizations that
will use the system; and
(5) identify barriers to sharing information and recommend
changes to the Data Practices Act to remove those barriers.
Subd. 2. [DATA STORAGE.] The departments of education,
administration, corrections, health and human services, and the
office of strategic and long-range planning must provide to the
legislature by January 30, 1995, a plan for storing essential
data elements for family service centers to use. This plan will
include reporting of data to the state as a by-product of both
family service and school district internal operations.
Subd. 3. [AGENCY SYSTEM INTEGRATION.] Any state agency or
department with programs serving children that is designing or
redesigning its information system must ensure that the
resulting information system can be fully integrated into the
statewide children's service database by June 30, 1995.
Agencies or departments must submit plans to design or redesign
information systems for review by the information policy office
to ensure that agency or department information can be fully
integrated into the statewide children's service database.
Sec. 48. Laws 1990, chapter 591, article 4, section 9, is
amended to read:
Sec. 9. [SUNSET.]
Sections 1 to 2, 3, 4, and 6, are repealed on June 30, 1995.
Sec. 49. Laws 1994, chapter 625, article 5, section 7, is
amended to read:
Sec. 7. [24-HOUR COVERAGE.]
As part of the implementation report submitted on January
1, 1996, as required under Minnesota Statutes, section 62Q.41,
The commissioners of health, commerce, and labor and industry
shall develop a 24-hour coverage plan, on a pilot project basis,
incorporating and coordinating the health component medical
benefits of workers' compensation with health care coverage
benefits to be offered by an integrated service network, health
maintenance organization, or an insurer or self-insured employer
under chapters 79, 79A, 176, 181, 62C, 62D, 62H, and 62N. The
commissioners shall also make provide the plan and
recommendations of any legislative changes that may be needed to
implement this plan, to the legislature by January 15, 1996.
Sec. 50. Laws 1994, chapter 625, article 5, section 10,
subdivision 2, is amended to read:
Subd. 2. [SCOPE OF STUDY.] The commissioner of health
shall continue the study developed as part of Minnesota
Statutes, section 62J.045, on study the impact of state health
care reform on the financing of medical education and research
activities in the state. The study shall address issues related
to the institutions engaged in these activities, including
hospitals, medical centers, and health plan companies, and will
report on the need for alternative funding mechanisms for
medical education and research activities. The commissioner
shall monitor ongoing public and private sector activities
related to the study of the financing of medical education and
research activities and include a description of these
activities in the final report as applicable. The commissioner
shall submit a report on the study findings, including
recommendations on mechanisms to finance medical education and
research activities, to the legislature by February 15, 1995
1996.
Sec. 51. [MALPRACTICE REFORM STUDY.]
The attorney general shall study issues related to medical
malpractice reform and shall present to the legislature, by
December 15, 1995, recommendations and draft legislation for
medical malpractice reforms that will reduce health care costs
in Minnesota. In developing these recommendations, the attorney
general shall consider medical malpractice laws in other states,
with particular attention to medical malpractice laws in
California.
Sec. 52. [HEALTH COVERAGE DEMONSTRATION PROJECT.]
Subdivision 1. [ESTABLISHMENT.] The commissioner of health
shall award a grant to regional coordinating board five to
develop a pilot project to provide information about health
coverage and advocacy services to individuals obtaining health
care services within the geographic area served by the regional
coordinating board. The board may contract with a nonprofit
organization to develop and administer the pilot project. The
pilot project must:
(1) provide individuals with assistance in interpreting the
terms of their certificate, contract, or policy of health
coverage, including but not limited to, terms relating to
covered services, limitations on services, limitations on access
to providers, and enrollee complaint and appeal procedures;
(2) maintain a current listing of health care providers
serving health plan company enrollees within regional
coordinating board five and assist individuals in determining
whether services provided by a specific provider are covered
under the health plan;
(3) assist and serve as advocates for enrollees in the
complaint and appeals process; and
(4) provide information supplied by the health plan
companies to individuals obtaining health care services within
the geographic area served by the regional coordinating board
regarding each company's expenditure and activity dedicated
directly to community-based prevention and health promotion.
The information supplied by the health plan company shall
include a description of the community-based prevention and
health promotion projects conducted or to be conducted in the
geographic area served by the regional coordinating board.
The commissioner of health and the commissioner of commerce
shall require all health plan companies serving enrollees within
regional coordinating board five to regularly provide the
regional coordinating board, or the entity under contract with
the board, with current listings of providers and current
certificates, contracts, or policies of coverage.
Subd. 2. [EVALUATION.] The commissioner of health, through
the office of rural health and in consultation with the
commissioner of commerce, shall evaluate the effectiveness of
the pilot project. The commissioner of health shall recommend
to the legislature by January 15, 1997, whether the pilot
project should be extended beyond the sunset date, and whether
the services provided by the pilot project should be made
available to enrollees living within the areas served by other
regional coordinating boards.
Subd. 3. [SUNSET.] This section expires July 1, 1997.
Sec. 53. [SURVEY OF LICENSURE RENEWAL.]
The legislative commission on health care access shall
survey medical doctors and doctors of osteopathy who have
discontinued their Minnesota licenses. The survey must identify
the reasons why licensed physicians fail to renew licenses and
determine whether the loss of licensed physicians is resulting
in increased problems in accessing medical care. The
legislative commission on health care access shall report survey
findings to the legislature by December 15, 1995.
Sec. 54. [ALTERNATIVE LICENSING MODEL FOR RURAL
HOSPITALS.]
The rural health advisory committee shall examine rural
health care access needs and present recommendations on the need
for an alternative licensing model for rural hospitals.
The committee must first examine:
(1) the projected demographics of rural populations;
(2) access to emergency care, obstetrics, and other
traditional hospital-based services;
(3) access issues related to transportation;
(4) health care needs of different regions of the state,
including those areas where access to care may be threatened by
the financial instability of local hospitals; and
(5) other factors related to access to rural health care
and hospital-based services.
Based upon this examination of access to health care in
rural areas, the committee shall evaluate the need for and the
feasibility of implementing an alternative licensing model for
rural hospitals. This evaluation must consider:
(1) the goals of an alternative licensing model;
(2) federal and state regulatory barriers and options for
reconfiguring traditional hospital-based health care services;
and
(3) the feasibility of implementing an alternative
licensing model, including the potential for integration with
integrated networks and likelihood of obtaining a Medicare
waiver and other necessary federal law changes.
If the committee determines that a need for an alternative
licensing model exists and implementation is feasible, the
committee shall identify changes needed in federal and state
law, and develop draft legislation for a Minnesota-specific
alternative licensing model.
The committee shall present a report to the legislature by
December 15, 1996. This report must summarize rural access
needs and present initial recommendations on the need for an
alternative licensing model for rural hospitals.
Sec. 55. [STUDY OF REGULATORY BARRIERS.]
The rural health advisory committee, in consultation with
the regional coordination boards, shall examine federal and
state regulatory barriers that limit rural access to care or
limit the ability of rural health care providers to provide care
efficiently, without improving the quality of care. The
commissioner of health shall provide staff and technical
assistance to the advisory committee and the regional
coordinating boards. The commissioner shall apply for federal
and private-sector grants and seek other nonstate sources of
funding to supplement state funds appropriated for this study.
The barriers to be studied must include, but are not limited to:
(1) requirements for emergency room staffing that increase
hospital costs and limit access to care;
(2) limits on the ability of nurses to prescribe and
administer prescription drugs under a physician's supervision in
emergency situations;
(3) state and federal inspection and regulatory
requirements that are duplicative and increase administrative
costs;
(4) physician supervision requirements that limit the use
of physician assistants; and
(5) the requirement that a hospital and its attached
nursing home have separate directors of nursing.
The advisory committee shall present recommendations for
eliminating these and other regulatory barriers to the
commissioner of health by December 1, 1995. The commissioner of
health shall consider these recommendations and shall present
recommendations and draft legislation to the legislature on any
needed changes in state and federal regulatory requirements, by
February 1, 1996.
Sec. 56. [REVISOR INSTRUCTION.]
(a) The revisor of statutes is instructed to change the
term "children's health plan" and similar terms to
"MinnesotaCare program" and similar terms, wherever in Minnesota
Statutes and Minnesota Rules the term "children's health plan"
and similar terms appear, including the revisor's heading that
immediately precedes Minnesota Statutes 1994, section 256.9351,
except that the revisor shall retain the reference to
"children's health plan" in Minnesota Statutes, section
256.9357, subdivision 1.
(b) The revisor of statutes is instructed to change the
title of Minnesota Statutes, chapter 62Q, to "REQUIREMENTS FOR
HEALTH PLAN COMPANIES."
Sec. 57. [REPEALER.]
Minnesota Statutes 1994, sections 62J.045; 62J.07,
subdivision 4; 62J.09, subdivision 1a; 62J.19; 62J.65; 144.1488,
subdivision 2; and 148.236, are repealed.
Laws 1993, chapter 247, article 1, sections 12, 13, 14, 15,
18, and 19, are repealed.
Sec. 58. [EFFECTIVE DATE.]
Sections 31 to 34, 39, and 48 are effective the day
following final enactment.
ARTICLE 9
FINANCING
Section 1. Minnesota Statutes 1994, section 16A.724, is
amended to read:
16A.724 [HEALTH CARE ACCESS FUND.]
A health care access fund is created in the state
treasury. The fund is a direct appropriated special revenue
fund. The commissioner shall deposit to the credit of the fund
money made available to the fund. Notwithstanding section
11A.20, after June 30, 1997, all investment income and all
investment losses attributable to the investment of the health
care access fund not currently needed shall be credited to the
health care access fund.
Sec. 2. Minnesota Statutes 1994, section 151.48, is
amended to read:
151.48 [OUT-OF-STATE WHOLESALE DRUG DISTRIBUTOR LICENSING
REQUIREMENTS.]
(a) It is unlawful for an out-of-state wholesale drug
distributor to conduct business in the state without first
obtaining a license from the board and paying the required fee.
(b) Application for an out-of-state wholesale drug
distributor license under this section shall be made on a form
furnished by the board.
(c) The issuance of a license under sections 151.42 to
151.51 shall not change or affect tax liability imposed by the
department of revenue on any out-of-state wholesale drug
distributor.
(d) No person acting as principal or agent for any
out-of-state wholesale drug distributor may sell or distribute
drugs in the state unless the distributor has obtained a license.
(e) (d) The board may adopt regulations that permit
out-of-state wholesale drug distributors to obtain a license on
the basis of reciprocity to the extent that an out-of-state
wholesale drug distributor:
(1) possesses a valid license granted by another state
under legal standards comparable to those that must be met by a
wholesale drug distributor of this state as prerequisites for
obtaining a license under the laws of this state; and
(2) can show that the other state would extend reciprocal
treatment under its own laws to a wholesale drug distributor of
this state.
Sec. 3. Minnesota Statutes 1994, section 270.101,
subdivision 1, is amended to read:
Subdivision 1. [LIABILITY IMPOSED.] A person who, either
singly or jointly with others, has the control of, supervision
of, or responsibility for filing returns or reports, paying
taxes, or collecting or withholding and remitting taxes and who
fails to do so, or a person who is liable under any other law,
is liable for the payment of taxes, penalties, and interest
arising under chapters 295, 296, 297, 297A, and 297C, or
sections 290.92 and 297E.02.
Sec. 4. Minnesota Statutes 1994, section 295.50,
subdivision 3, is amended to read:
Subd. 3. [GROSS REVENUES.] "Gross revenues" are total
amounts received in money or otherwise by:
(1) a resident hospital for patient services;
(2) a resident surgical center for patient services;
(3) a nonresident hospital for patient services provided to
patients domiciled in Minnesota;
(4) a nonresident surgical center for patient services
provided to patients domiciled in Minnesota;
(5) a resident health care provider, other than a staff
model health carrier, for patient services;
(6) a nonresident health care provider for patient services
provided to an individual domiciled in Minnesota or patient
services provided in Minnesota;
(7) a wholesale drug distributor for sale or distribution
of legend drugs that are delivered: (i) to a Minnesota resident
by a wholesale drug distributor who is a nonresident pharmacy
directly, by common carrier, or by mail; or (ii) in Minnesota by
the wholesale drug distributor, by common carrier, or by mail,
unless the legend drugs are delivered to another wholesale drug
distributor who sells legend drugs exclusively at wholesale.
Legend drugs do not include nutritional products as defined in
Minnesota Rules, part 9505.0325;
(8) a staff model health plan company as gross premiums for
enrollees, copayments, deductibles, coinsurance, and fees for
patient services covered under its contracts with groups and
enrollees;
(9) a resident pharmacy for medical supplies, appliances,
and equipment; and
(10) a nonresident pharmacy for medical supplies,
appliances, and equipment provided to consumers domiciled in
Minnesota or delivered into Minnesota.
Sec. 5. Minnesota Statutes 1994, section 295.50,
subdivision 4, is amended to read:
Subd. 4. [HEALTH CARE PROVIDER.] (a) "Health care
provider" means:
(1) a person furnishing any or all of the following goods
or services directly to a patient or consumer: medical,
surgical, optical, visual, dental, hearing, nursing services,
drugs, medical supplies, medical appliances, laboratory,
diagnostic or therapeutic services, or any goods and services
not listed above that qualifies for reimbursement under the
medical assistance program provided under chapter 256B. For
purposes of this clause, "directly to a patient or consumer"
includes goods and services provided in connection with
independent medical examinations under section 65B.56 or other
examinations for purposes of litigation or insurance claims;
(2) a staff model health plan company; or
(3) a licensed ambulance service.
(b) Health care provider does not include hospitals,
nursing homes licensed under chapter 144A, pharmacies, and
surgical centers.
Sec. 6. Minnesota Statutes 1994, section 295.50,
subdivision 10a, is amended to read:
Subd. 10a. [PHARMACY.] "Pharmacy" means a pharmacy, as
defined in section 151.01 required to be licensed under chapter
151, or a pharmacy required to be licensed by any other
jurisdiction.
Sec. 7. Minnesota Statutes 1994, section 295.53,
subdivision 1, is amended to read:
Subdivision 1. [EXEMPTIONS.] (a) The following payments
are excluded from the gross revenues subject to the hospital,
surgical center, or health care provider taxes under sections
295.50 to 295.57:
(1) payments received for services provided under the
Medicare program, including payments received from the
government, and organizations governed by sections 1833 and 1876
of title XVIII of the federal Social Security Act, United States
Code, title 42, section 1395, and enrollee deductibles,
coinsurance, and copayments, whether paid by the individual
Medicare enrollee or by insurer or other third party a Medicare
supplemental coverage as defined in section 62A.011, subdivision
3, clause (10). Payments for services not covered by Medicare
are taxable;
(2) medical assistance payments including payments received
directly from the government or from a prepaid plan;
(3) payments received for home health care services;
(4) payments received from hospitals or surgical centers
for goods and services on which liability for tax is imposed
under section 295.52 or the source of funds for the payment is
exempt under clause (1), (2), (7), (8), or (10);
(5) payments received from health care providers for goods
and services on which liability for tax is imposed under
sections 295.52 to 295.57 or the source of funds for the payment
is exempt under clause (1), (2), (7), (8), or (10);
(6) amounts paid for legend drugs, other than nutritional
products, to a wholesale drug distributor reduced by
reimbursements received for legend drugs under clauses (1), (2),
(7), and (8);
(7) payments received under the general assistance medical
care program including payments received directly from the
government or from a prepaid plan;
(8) payments received for providing services under the
MinnesotaCare program including payments received directly from
the government or from a prepaid plan and enrollee deductibles,
coinsurance, and copayments;. For purposes of this clause,
coinsurance means the portion of payment that the enrollee is
required to pay for the covered service;
(9) payments received by a resident health care provider or
the wholly owned subsidiary of a resident health care provider
for care provided outside Minnesota to a patient who is not
domiciled in Minnesota;
(10) payments received from the chemical dependency fund
under chapter 254B;
(11) payments received in the nature of charitable
donations that are not designated for providing patient services
to a specific individual or group;
(12) payments received for providing patient services if
the services are incidental to conducting medical
research incurred through a formal program of health care
research conducted in conformity with federal regulations
governing research on human subjects. Payments received from
patients or from other persons paying on behalf of the patients
are subject to tax;
(13) payments received from any governmental agency for
services benefiting the public, not including payments made by
the government in its capacity as an employer or insurer;
(14) payments received for services provided by community
residential mental health facilities licensed under Minnesota
Rules, parts 9520.0500 to 9520.0690, community support programs
and family community support programs approved under Minnesota
Rules, parts 9535.1700 to 9535.1760, and community mental health
centers as defined in section 245.62, subdivision 2;
(15) government payments received by a regional treatment
center;
(16) payments received for hospice care services;
(17) payments received by a resident health care provider
or the wholly owned subsidiary of a resident health care
provider for medical supplies, appliances and equipment
delivered outside of Minnesota;
(18) payments received for services provided by community
supervised living facilities for persons with mental retardation
or related conditions licensed under Minnesota Rules, parts
4665.0100 to 4665.9900;
(19) payments received by a post-secondary educational
institution from student tuition, student activity fees, health
care service fees, government appropriations, donations, or
grants. Fee for service payments and payments for extended
coverage are taxable; and
(20) payments received for services provided by:
residential care homes licensed under chapter 144B; board and
lodging establishments providing only custodial services, that
are licensed under chapter 157 and registered under section
157.031 to provide supportive services or health supervision
services; and assisted living programs, congregate housing
programs, and other senior housing options.
(b) Payments received by wholesale drug distributors for
prescription drugs sold directly to veterinarians or veterinary
bulk purchasing organizations are excluded from the gross
revenues subject to the wholesale drug distributor tax under
sections 295.50 to 295.59.
Sec. 8. Minnesota Statutes 1994, section 295.53,
subdivision 3, is amended to read:
Subd. 3. [RESTRICTION ON ITEMIZATION SEPARATE STATEMENT OF
TAX.] A hospital, surgical center, pharmacy, or health care
provider must not separately state the tax obligation under
section 295.52 on bills provided to individual patients in a
deceptive or misleading manner. It must not separately state
tax obligations on bills provided to patients, consumers, or
other payers when the amount received for the services or goods
is not subject to tax.
Pharmacies that separately state the tax obligations on
bills provided to consumers or to other payers who purchase
legend drugs may state the tax obligation as two percent of the
wholesale price of the legend drugs. Pharmacies must not state
the tax obligation as two percent of the retail price.
Whenever the commissioner determines that a person has
engaged in any act or practice constituting a violation of this
subdivision, the commissioner may bring an action in the name of
the state in the district court of the appropriate county to
enjoin the act or practice and to enforce compliance with this
subdivision, or the commissioner may refer the matter to the
attorney general or the county attorney of the appropriate
county. Upon a proper showing, a permanent or temporary
injunction, restraining order, or other appropriate relief must
be granted.
Sec. 9. Minnesota Statutes 1994, section 295.53,
subdivision 4, is amended to read:
Subd. 4. [DEDUCTION FOR RESEARCH.] (a) In addition to the
exemptions allowed under subdivision 1, a hospital or health
care provider which is exempt under section 501(c)(3) of the
Internal Revenue Code of 1986 or is owned and operated under
authority of a governmental unit, may deduct from its gross
revenues subject to the hospital or health care provider taxes
under sections 295.50 to 295.57 revenues equal to expenditures
for allowable research programs.
(b) For purposes of this subdivision, expenditures for
allowable research programs are the direct and general program
costs for activities which are part of a formal program of
medical and health care research approved by the governing body
of the hospital or health care provider which also includes
active solicitation of research funds from government and
private sources. Any Allowable research on humans or animals
must:
(1) have as its purpose the development of new knowledge in
basic or applied science relating to the diagnosis and treatment
of conditions affecting the human body;
(2) be subject to review by appropriate regulatory
committees by individuals with expertise in the subject matter
of the proposed study but who have no financial interest in the
proposed study and are not involved in the conduct of the
proposed study; and
(3) be subject to review and supervision by an
institutional review board operating in conformity with federal
regulations such as an institutional review board if the
research involves human subjects or an institutional animal care
and use committee operating in conformity with federal
regulations if the research involves animal subjects. Research
expenses are not exempt if the study is a routine evaluation of
health care methods or products used in a particular setting
conducted for the purpose of making a management decision.
Costs of clinical research activities paid directly for the
benefit of an individual patient are excluded from this
exemption. Basic research in fields including biochemistry,
molecular biology, and physiology are also included if such
programs are subject to a peer review process.
(c) No deduction shall be allowed under this subdivision
for any revenue received by the hospital or health care provider
in the form of a grant, gift, or otherwise, whether from a
government or nongovernment source, on which the tax liability
under section 295.52 is not imposed or for which the tax
liability under section 295.52 has been received from a third
party as provided for in section 295.582.
(d) Effective beginning with calendar year 1995, the
taxpayer shall not take the deduction under this section into
account in determining estimated tax payments or the payment
made with the annual return under section 295.55. The total
deduction allowable to all taxpayers under this section for
calendar years beginning after December 31, 1994, may not exceed
$65,000,000. To implement this limit, each qualifying hospital
and qualifying health care provider shall submit to the
commissioner by March 15 its total expenditures qualifying for
the deduction under this section for the previous calendar
year. The commissioner shall sum the total expenditures of all
taxpayers qualifying under this section for the calendar year.
If the resulting amount exceeds $65,000,000, the commissioner
shall allocate a part of the $65,000,000 deduction limit to each
qualifying hospital and health care provider in proportion to
its share of the total deductions. The commissioner shall pay a
refund to each qualifying hospital or provider equal to its
share of the deduction limit multiplied by two percent. The
commissioner shall pay the refund no later than May 15 of the
calendar year.
Sec. 10. Minnesota Statutes 1994, section 295.55,
subdivision 4, is amended to read:
Subd. 4. [ELECTRONIC FUNDS TRANSFER PAYMENTS.] A taxpayer
with an aggregate tax liability of $30,000 or more during a
calendar quarter ending the last day of March, June, September,
or December of the first year the taxpayer is subject to the tax
must remit all liabilities by means of a funds transfer as
defined in section 336.4A-104, paragraph (a), for the remainder
of the year. A taxpayer with an aggregate tax liability of
$120,000 or more during a calendar fiscal year ending June 30,
must remit all liabilities by means of a funds transfer as
defined in section 336.4A-104, paragraph (a), in the subsequent
calendar year. The funds transfer payment date, as defined in
section 336.4A-401, is on or before the date the tax is due. If
the date the tax is due is not a funds-transfer business day, as
defined in section 336.4A-105, paragraph (a), clause (4), the
payment date is on or before the first funds-transfer business
day after the date the tax is due.
Sec. 11. [295.56] [TRANSFER OF ACCOUNTS RECEIVABLE.]
When a hospital or health care provider transfers, assigns,
or sells accounts receivable to another person who is subject to
tax under this chapter, liability for the tax on the accounts
receivable is imposed on the transferee, assignee, or buyer of
the accounts receivable. No liability for these accounts
receivable is imposed on the transferor, assignor, or seller of
the accounts receivable.
Sec. 12. Minnesota Statutes 1994, section 295.57, is
amended to read:
295.57 [COLLECTION AND ENFORCEMENT; REFUNDS; RULEMAKING;
APPLICATION OF OTHER CHAPTERS; ACCESS TO RECORDS.]
Subdivision 1. [APPLICATION OF OTHER CHAPTERS.] Unless
specifically provided otherwise by sections 295.50 to 295.58,
the enforcement, interest, and penalty provisions under chapter
294, appeal provisions in sections 289A.43 and 289A.65, criminal
penalties in section 289A.63, and refunds provisions in section
289A.50, and collection and rulemaking provisions under chapter
270, apply to a liability for the taxes imposed under sections
295.50 to 295.58.
Subd. 2. [ACCESS TO RECORDS.] For purposes of
administering the taxes imposed by sections 295.50 to 295.59,
the commissioner may access patients' records that contain
billing or other financial information without prior consent
from the patients. The data collected is classified as private
or nonpublic data.
Sec. 13. [295.581] [PROHIBITION ON NON-MINNESOTACARE
TRANSFERS FROM FUND.]
Notwithstanding any law to the contrary, and
notwithstanding section 645.33, money in the health care access
fund shall be appropriated only for purposes that are consistent
with past and current MinnesotaCare appropriations in Laws 1992,
chapter 549; Laws 1993, chapter 345; Laws 1994, chapter 625; and
this act or for initiatives that are part of the section 1115 of
the Social Security Act health care reform waiver submitted to
the federal health care financing administration by the
commissioner of human services as appropriated in this act.
Sec. 14. Minnesota Statutes 1994, section 295.582, is
amended to read:
295.582 [AUTHORITY.]
(a) A hospital, surgical center, pharmacy, or health care
provider that is subject to a tax under section 295.52, or a
pharmacy that has paid additional expense transferred under this
section by a wholesale drug distributor, may transfer additional
expense generated by section 295.52 obligations on to all
third-party contracts for the purchase of health care services
on behalf of a patient or consumer. The additional expense
transferred to the third-party purchaser must not exceed two
percent of the gross revenues received under the third-party
contract, plus and two percent of copayments and deductibles
paid by the individual patient or consumer. The expense must
not be generated on revenues derived from payments that are
excluded from the tax under section 295.53. All third-party
purchasers of health care services including, but not limited
to, third-party purchasers regulated under chapter 60A, 62A,
62C, 62D, 62H, 62N, 64B, 65A, 65B, 79, or 79A, or under section
471.61 or 471.617, must pay the transferred expense in addition
to any payments due under existing contracts with the hospital,
surgical center, pharmacy, or health care provider, to the
extent allowed under federal law. A third-party purchaser of
health care services includes, but is not limited to, a health
carrier, integrated service network, or community integrated
service network that pays for health care services on behalf of
patients or that reimburses, indemnifies, compensates, or
otherwise insures patients for health care services. A
third-party purchaser shall comply with this section regardless
of whether the third-party purchaser is a for-profit,
not-for-profit, or nonprofit entity. A wholesale drug
distributor may transfer additional expense generated by section
295.52 obligations to entities that purchase from the
wholesaler, and the entities must pay the additional expense.
Nothing in this section limits the ability of a hospital,
surgical center, pharmacy, wholesale drug distributor, or health
care provider to recover all or part of the section 295.52
obligation by other methods, including increasing fees or
charges.
(b) Each third-party purchaser regulated under any chapter
cited in paragraph (a) shall include with its annual renewal for
certification of authority or licensure documentation indicating
compliance with paragraph (a). If the commissioner responsible
for regulating the third-party purchaser finds at any time that
the third-party purchaser has not complied with paragraph (a),
the commissioner may by order fine or censure the third-party
purchaser or revoke or suspend the certificate of authority or
license of the third-party purchaser to do business in this
state. The third-party purchaser may appeal the commissioner's
order through a contested case hearing in accordance with
chapter 14.
Sec. 15. [EFFECTIVE DATE.]
Sections 2 and 6 are effective the day following final
enactment.
Sections 3, 7, and 10 are effective for tax periods
beginning on or after January 1, 1996.
Section 4 is effective for services provided on or after
July 1, 1995.
Section 5 is effective January 1, 1995.
Section 8 is effective for statements of the tax made on or
after July 1, 1995.
Section 9 is effective for research deductions incurred on
or after July 1, 1995.
Section 11 is effective for transfers of accounts
receivable on or after July 1, 1995.
Section 12 is effective for audits conducted on or after
the day following final enactment.
Section 13, prohibiting non-MinnesotaCare transfers from
the health care access fund, is effective the day following
final enactment.
ARTICLE 10
HEALTH PROVIDER COOPERATIVES
Section 1. [62R.17] [PROVIDER COOPERATIVE DEMONSTRATION.]
A health provider cooperative incorporated and having
adopted bylaws before May 1, 1995, that has members who provide
services in Sibley, Nicollet, Blue Earth, Brown, Watonwan,
Martin, Faribault, Waseca, and LeSueur counties, may contract
with a qualified employer or self-insured employer plan to
provide health care services in accordance with sections 62R.17
to 62R.26. The health provider cooperative, the qualified
employer, or the self-insured employer plan shall not, solely on
account of that contract, be subject to any provision of
Minnesota Statutes relating to health carriers except as
provided in section 62R.21. The grant of contracting power
under this section shall not be interpreted to permit or
prohibit any other lawful arrangement between a health care
provider and a self-insured employee welfare benefit plan or its
sponsor.
Sec. 2. [62R.18] [DEFINITIONS.]
Subdivision 1. [APPLICATION.] For purposes of sections
62R.17 to 62R.26, the terms defined in this section have the
meanings given.
Subd. 2. [HEALTH CARRIER.] "Health carrier" means a health
carrier as defined in section 62A.011.
Subd. 3. [PLAN PARTICIPANT.] "Plan participant" means an
eligible employee or retiree of a qualified employer or an
eligible dependent of an employee or retired employee of a
qualified employer.
Subd. 4. [QUALIFIED EMPLOYER.] "Qualified employer" means
an employer sponsoring or maintaining a self-insured employer
plan meeting the requirements of sections 62R.19 and 62R.21.
Subd. 5. [SELF-INSURED EMPLOYER PLAN.] "Self-insured
employer plan" means a plan, fund, or program established or
maintained by a qualified employer on or before January 1, 1995,
for the purpose of providing medical, surgical, hospital, or
other health care benefits to plan participants primarily on a
self-insured basis. A governmental joint self-insurance plan
established under chapter 471 is a self-insured employer plan
for purposes of this definition.
Sec. 3. [62R.19] [STOP LOSS REQUIREMENT.]
A health provider cooperative shall not contract with a
qualified employer or self-insured employer plan under section
62R.17 unless the qualified employer or self-insured employer
plan maintains a policy of stop loss or excess loss insurance
from an insurance company licensed to do business in this state
in accordance with the following:
(1) A qualified employer with more than 750 employees as
defined in section 62L.02 must not maintain a policy of stop
loss, excess loss, or similar coverage with an attachment point
less than 120 percent of the self-insured employer plan's annual
expected benefit costs;
(2) A qualified employer with 200 or more but fewer than
750 employees as defined in section 62L.02 must maintain a
policy providing aggregate stop loss insurance with an annual
attachment point of no less than 120 percent of the self-insured
employer plan's annual expected benefit costs and providing
individual stop loss coverage with a deductible of no less than
$10,000; and
(3) A qualified employer with fewer than 200 employees as
defined in section 62L.02 must maintain a policy meeting the
requirements of section 60A.235.
Sec. 4. [62R.20] [CONTRACT REQUIREMENTS.]
Any contract for health care services described in section
62R.17 is subject to the following requirements:
(1) The contract must be structured so that the health
provider cooperative does not bear financial risk in excess of
50 percent of the self-insured employer plan's expected annual
costs.
(2) The contract must not be effective prior to January 1,
1996.
(3) The contract must be limited to those services
regularly provided by the cooperative or its members.
(4) The contract must obligate the qualified employer to
maintain its self-insured employer plan in accordance with
section 62R.21.
Sec. 5. [62R.21] [PLAN REQUIREMENTS.]
The requirements described in section 62R.20, clause (4),
are as follows:
(1) The plan shall not exclude any eligible employees or
their dependents, both as defined in section 62L.02, from
coverage offered by the employer, under this paragraph or any
other health coverage, insured or self-insured, offered by the
employer, on the basis of the health status or health history of
the person.
(2) Contributions to the cost of the self-insured employer
plan from plan participants must not be based upon the gender of
the plan participant.
Sec. 6. [62R.22] [PARTICIPANT HOLD HARMLESS.]
The health provider cooperative and its members and patrons
must not have recourse against the plan participants of any
self-insured employer plan with which the cooperative has
contracted in accordance with sections 62R.17 to 62R.26, except
for collection of copayments, coinsurance, or deductibles, or
for health care services rendered that are not covered by the
self-insured employer plan or that are in excess of the lifetime
maximum benefit limit. This requirement applies to, but is not
limited to, nonpayment of the cooperative by the self-insured
employer plan or qualified employer, insolvency of the qualified
employer, insolvency of the health provider cooperative, or
nonpayment by the cooperative to the cooperative member or
patron.
Sec. 7. [62R.23] [CONTINUATION OF CARE.]
In the event of the insolvency or bankruptcy of a qualified
employer, a health provider cooperative described in section
62R.17 and its members shall continue to deliver the contracted
health care services to plan participants for a period of 30
days, whether or not the cooperative receives payment from the
qualified employer, its estate in bankruptcy, or from the
self-insured employer plan. Section 62R.22 applies to this
section. Nothing in this section, however, limits the right of
the cooperative to seek payment from the qualified employer, its
estate, or the self-insured employer plan for services so
rendered.
Sec. 8. [62R.24] [TAXES AND ASSESSMENTS.]
Effective January 1, 1998, as a condition to entering a
contract described in section 62R.17, a self-insured employer
plan or the qualified employer must voluntarily pay the one
percent premium tax imposed in section 60A.15, subdivision 1,
paragraph (d), and assessments by the Minnesota Comprehensive
Health Association.
Sec. 9. [62R.25] [NOTIFICATION OF CONTRACT; REPORT TO
LEGISLATURE.]
(a) Each health provider cooperative shall notify the
Office of Rural Health in writing upon entering a contract
described in section 62R.17.
(b) The Department of Health, Office of Rural Health, shall
provide an information report to the MinnesotaCare Finance
Division of the House Health and Human Services Committee and
the Senate Health Care Committee no later than January 15, 1999,
on the status of direct contracting between health provider
cooperatives and self-insured employer plans or qualified
employers in accordance with sections 62R.17 to 62R.26. The
report shall consider the effects on public policy and on health
provider cooperatives of a possible requirement that health
provider cooperatives using direct contracting be obligated to
become community integrated service networks.
Sec. 10. [62R.26] [SUNSET.]
Sections 62R.17 to 62R.25 expire on December 31, 1999.
Sec. 11. [EFFECTIVE DATE.]
Sections 1 to 10 are effective the day following final
enactment.
ARTICLE 11
APPROPRIATIONS
Section 1. [APPROPRIATIONS; SUMMARY.]
Except as otherwise provided in this act, the sums set
forth in the columns designated "fiscal year 1996" and "fiscal
year 1997" are appropriated from the general fund, or other
named fund, to the agencies for the purposes specified in this
act for the fiscal years ending June 30, 1996, and June 30, 1997.
Sec. 2. APPROPRIATIONS
SUMMARY BY FUND
1996 1997 TOTAL
Health Care
Access Fund $ 98,472,000 $145,882,000 $244,354,000
State Government
Special Revenue $ 413,000 $ 557,000 $ 970,000
Subdivision 1. Department of Human
Services
Health Care
Access Fund $ 85,420,000 $133,740,000 $219,160,000
[FEDERAL RECEIPTS FOR ADMINISTRATION.]
Receipts received as a result of
federal participation pertaining to
administrative costs of the Minnesota
Health Care Reform Waiver shall be
deposited as a nondedicated revenue to
the Health Care Access Fund, while
receipts received as a result of
federal participation pertaining to
grants shall be deposited to the
federal fund and shall offset health
care access funds for payments to
providers.
[1115 WAIVER] Of this appropriation
$695,000 in the fiscal year beginning
July 1, 1995 and $855,000 in the fiscal
year beginning July 1, 1996, is for
administration of the section 1115
federal waiver. This appropriation
shall not become part of the base for
the fiscal year 1998-1999 biennium.
[SENIOR DRUG PROGRAM ADMINISTRATION.]
Fees for the senior drug discount
program are appropriated to and may be
retained by the commissioner in the
health care access fund for the purpose
of administration of enrollment for the
program.
Subd. 2. Department of Employee
Relations
Health Care
Access Fund 1,000,000 .,...,-0-,... 1,000,000
Subd. 3. Department of Health
Health Care
Access Fund 7,609,000 7,528,000 15,137,000
State Government
Special Revenue 413,000 557,000 970,000
[1-800 PHONE LINE.] Of this
appropriation, $90,000 is for the
fiscal year beginning July 1, 1996, for
the operation of a 1-800 resource phone
line for information on programs and
services with children with special
health care needs, and to conduct
outreach and communications activities
related to this resource phone line.
The commissioner shall evaluate the
effectiveness of this program and
report to the House MinnesotaCare
Finance Division and the Senate Health
Care Committee by January 15, 1997.
This appropriation shall not become
part of the base for the fiscal year
1998-1999 biennium.
[HEALTH COVERAGE DEMONSTRATION GRANT.]
Of this appropriation, $100,000 is for
the fiscal year beginning July 1, 1996,
for implementation of the health
coverage demonstration project. This
appropriation shall not become part of
the base for the fiscal year 1998-1999
biennium.
[STATE GOVERNMENT SPECIAL REVENUE
FUND.]Fees collected from integrated
service networks and community
integrated service networks shall be
deposited in the state government
special revenue fund.
[COMPARATIVE PERFORMANCE MEASURES.] Of
this appropriation, $150,000 for the
fiscal year beginning July 1, 1995, and
$150,000 for the fiscal year beginning
July 1, 1996, is for a grant to the
Minnesota Health Data Institute, to
transfer the responsibility for the
development and implementation of
comparative performance measurement.
[ALTERNATIVE LICENSING.] Of this
appropriation, $50,000 for the fiscal
year beginning July 1, 1995, is for an
evaluation of alternative hospital
licensing models. Unspent funds may be
carried forward to the fiscal year
beginning July 1, 1996.
Subd. 4. University of Minnesota
Health Care
Access Fund 2,867,000 3,082,000 5,949,000
[AHEC GRANT.] Of this appropriation,
$100,000 for the fiscal year beginning
July 1, 1996, is to match federal
funding received through the area
health education center grant applied
for under Minnesota Statutes, section
137.42. This appropriation is
available to the board of regents only
if the University of Minnesota-Duluth
School of Medicine receives a federal
area health education center grant.
This appropriation shall not become
part of the base for the fiscal year
1998-1999 biennium.
[PHYSICIAN SUBSTITUTE DEMONSTRATION
PROJECT.] Of this appropriation,
$85,000 for the fiscal year beginning
July 1, 1995, is for costs incurred by
the academic health center in
credentialing physician substitutes and
employing physician substitutes as
temporary clinical faculty under
Minnesota Statutes, section 137.43.
The academic health center must report
to the House MinnesotaCare Finance
Division and the Senate Health Care
Committee by February 15, 1996, on
progress in credentially and employing
physician substitutes under Minnesota
Statutes, section 137.43. Unspent
funds may be carried forward to the
fiscal year beginning July 1. 1996.
[PRIMARY CARE TRAINING INITIATIVE.] Of
this appropriation, $125,000 for the
fiscal year beginning July 1, 1995, and
$125,000 for the fiscal year beginning
July 1, 1996, is for increasing the
number of primary care physicians in
Minnesota as requested in Minnesota
Statutes, section 137.38, subdivision
3. This appropriation is available
only if the University can provide
evidence of matching funding. This
appropriation shall not become part of
the base for the fiscal year 1998-1999
biennium.
[INDIGENT DENTAL CARE.] Of this
appropriation, $300,000 for the fiscal
year beginning July 1, 1995, and
$300,000 for the fiscal year beginning
July 1, 1996, is to cover the cost of
indigent care at the University of
Minnesota Dental School. This
appropriation shall not become part of
the base for the fiscal year 1998-1999
biennium.* (The preceding paragraph
beginning "[INDIGENT DENTAL CARE.]" was
vetoed by the governor.)
[UMD MEDICAL SCHOOL.] Of this
appropriation, $200,000 for the fiscal
year beginning July 1, 1996, is for the
University of Minnesota-Duluth. This
appropriation shall not become part of
the base for the fiscal year 1998-1999
biennium.* (The preceding paragraph
beginning "[UMD MEDICAL SCHOOL.]" was
vetoed by the governor.)
Subd. 5. Department of Revenue
Health Care
Access Fund 1,375,000 1,381,000 2,756,000
Subd. 6. Department of Commerce
Health Care
Access Fund 26,000 26,000 52,000
Subd. 7. Legislative Coordinating
Commission
Health Care
Access Fund 175,000 125,000 300,000
Presented to the governor May 23, 1995
Signed by the governor May 25, 1995, 2:32 p.m.
Official Publication of the State of Minnesota
Revisor of Statutes