1.1                          A bill for an act
  1.2             relating to insurance; requiring certain insurers to 
  1.3             cover care provided by any licensed provider willing 
  1.4             to serve the insurer's enrollees; proposing coding for 
  1.5             new law in Minnesota Statutes, chapter 62Q; repealing 
  1.6             Minnesota Statutes 1996, section 62Q.095. 
  1.7   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.8      Section 1.  [62Q.61] [DEFINITIONS.] 
  1.9      Subdivision 1.  [APPLICABILITY.] For purposes of sections 
  1.10  62Q.61 to 62Q.63, the terms defined in this section have the 
  1.11  meanings given. 
  1.12     Subd. 2.  [ENROLLEE.] "Enrollee" has the meaning given in 
  1.13  section 62Q.01, subdivision 2a. 
  1.14     Subd. 3.  [ENROLLEE COST-SHARING.] "Enrollee cost-sharing" 
  1.15  means the portion of a health care provider's charge that the 
  1.16  enrollee is required to pay under the terms of the health plan 
  1.17  for goods and services covered by the health plan.  Enrollee 
  1.18  cost-sharing includes deductibles; copayments; coinsurance; 
  1.19  charges in excess of annual, lifetime, or similar limits; and 
  1.20  charges in excess of the amount approved by the health plan 
  1.21  company. 
  1.22     Subd. 4.  [GATEKEEPER SYSTEM.] "Gatekeeper system" means a 
  1.23  system of administration used by a health plan company in 
  1.24  connection with a health plan in which a primary care provider 
  1.25  furnishes basic patient care and coordinates diagnostic testing, 
  1.26  indicated treatment, and specialty referral for enrollees in the 
  2.1   health plan. 
  2.2      Subd. 5.  [HEALTH CARE PROVIDER.] (a) "Health care provider"
  2.3   means an independently enrolled audiologist, chemical dependency 
  2.4   treatment facility, chiropractor, community clinic, community 
  2.5   mental health center, dentist, dietitian, home health care 
  2.6   provider, hospital, licensed marriage and family therapist, 
  2.7   nurse practitioner or advanced practice nurse, nursing facility, 
  2.8   occupational therapist, optometrist, optician, outpatient 
  2.9   chemical dependency counselor, outpatient surgical center, 
  2.10  pharmacist, osteopath, physical therapist, physician, 
  2.11  podiatrist, licensed psychologist, psychological practitioner, 
  2.12  licensed social worker, rural health clinic, or speech therapist.
  2.13     (b) For purposes of this subdivision, "home health care 
  2.14  provider" means a provider of personal care assistance, home 
  2.15  health aides, homemakers, respite care, adult day care, or home 
  2.16  therapies and home health nursing services. 
  2.17     (c) For purposes of this subdivision, "independently 
  2.18  enrolled" means that the health care provider has authority 
  2.19  under state law to bill, and receive payment directly from, a 
  2.20  patient or health plan company. 
  2.21     Subd. 6.  [HEALTH CARE SERVICES.] "Health care services" 
  2.22  means goods and services provided by a health care provider 
  2.23  within the scope of the health care provider's license. 
  2.24     Subd. 7.  [HEALTH PLAN.] "Health plan" has the meaning 
  2.25  given in section 62Q.01, subdivision 3, but includes the 
  2.26  coverages that are excluded under section 62A.011, subdivision 
  2.27  3, clauses (6), (7), (8), (10), and (12). 
  2.28     Subd. 8.  [HEALTH PLAN COMPANY.] "Health plan company" has 
  2.29  the meaning given in section 62Q.01, subdivision 4. 
  2.30     Sec. 2.  [62Q.62] [ENROLLEE CHOICE OF PROVIDER REQUIRED.] 
  2.31     Subdivision 1.  [INTERFERENCE WITH CHOICE PROHIBITED.] A 
  2.32  health plan company shall not directly or indirectly in 
  2.33  connection with a health plan: 
  2.34     (1) impose higher enrollee cost-sharing or reduced 
  2.35  reimbursement for health care services that would affect an 
  2.36  enrollee's choice among those health care providers who 
  3.1   participate in the health plan according to the terms offered; 
  3.2      (2) impose upon an enrollee under a health plan a 
  3.3   copayment, fee, or condition that is not equally imposed upon 
  3.4   all enrollees in the same benefit category, class, or enrollee 
  3.5   cost-sharing level under the health plan when the enrollee is 
  3.6   receiving health care services from a participating health care 
  3.7   provider under that health plan; or 
  3.8      (3) prohibit or limit an enrollee's coverage for covered 
  3.9   health care services provided by a health care provider that is 
  3.10  qualified under section 62Q.61, subdivision 5, and is willing to 
  3.11  accept the health plan's operating terms and conditions, 
  3.12  schedule of fees, covered expenses, and utilization regulations. 
  3.13     Subd. 2.  [QUALITY AND COST CONTROL PERMITTED.] Nothing in 
  3.14  sections 62Q.61 to 62Q.63 prevents a health plan company from 
  3.15  using measures designed to maintain quality and to control 
  3.16  costs, including, but not limited to, the use of a gatekeeper 
  3.17  system, so long as those measures are imposed equally on all 
  3.18  health care providers of the same type. 
  3.19     Subd. 3.  [INTERPRETATION.] Nothing in sections 62Q.61 to 
  3.20  62Q.63: 
  3.21     (1) requires a health plan to cover a specific health care 
  3.22  service; or 
  3.23     (2) permits a condition or measure that would have the 
  3.24  effect of excluding a type or class of health care provider 
  3.25  qualified under subdivision 1, clause (3), from providing health 
  3.26  care services to a health plan's enrollees. 
  3.27     Sec. 3.  [62Q.63] [VIOLATIONS; APPLICABILITY.] 
  3.28     Subdivision 1.  [VIOLATIONS.] A health plan company shall 
  3.29  not offer, sell, issue, or renew a health plan that fails to 
  3.30  comply with sections 62Q.61 to 62Q.63.  Actions taken to 
  3.31  maintain quality, enforce utilization regulations, and control 
  3.32  costs are not violations.  The commissioner, as defined in 
  3.33  section 62Q.01, subdivision 2, shall enforce those sections. 
  3.34     Subd. 2.  [CIVIL REMEDIES.] A person adversely affected by 
  3.35  a violation of sections 62Q.61 to 62Q.63 may sue in a court of 
  3.36  competent jurisdiction for injunctive relief against the health 
  4.1   plan company and, upon prevailing, shall in addition to the 
  4.2   injunctive relief recover damages of not less than $1,000, 
  4.3   reasonable attorney fees, and costs. 
  4.4      Subd. 3.  [CONTRARY PROVISIONS VOID.] A provision of a 
  4.5   health plan that conflicts with sections 62Q.61 to 62Q.63 is 
  4.6   void to the extent of the conflict. 
  4.7      Subd. 4.  [APPLICABILITY.] Sections 62Q.61 to 62Q.63 do not 
  4.8   apply to the extent that they are preempted by federal law. 
  4.9      Sec. 4.  [REPEALER; EXPANDED PROVIDER NETWORK.] 
  4.10     Minnesota Statutes 1996, section 62Q.095, is repealed. 
  4.11     Sec. 5.  [EFFECTIVE DATE.] 
  4.12     Sections 1 to 3 are effective January 1, 1999, and apply to 
  4.13  health plans issued or renewed on or after that date.  Section 4 
  4.14  is effective January 1, 1999.