HF 779

1st Engrossment - 88th Legislature (2013 - 2014) Posted on 03/11/2013 03:57pm

A bill for an act
relating to health plan regulation; establishing health plan market rules;
modifying the designation of essential community providers; amending
Minnesota Statutes 2012, section 62Q.19, subdivision 1; proposing coding for
new law as Minnesota Statutes, chapter 62K.

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

Section 1.

new text begin [62K.01] TITLE.
new text end

new text begin This chapter may be cited as the "Minnesota Health Plan Market Rules."
new text end

Sec. 2.

new text begin [62K.02] PURPOSE AND SCOPE.
new text end

new text begin Subdivision 1. new text end

new text begin Purpose. new text end

new text begin The market rules set forth in this chapter serve to clarify
and provide guidance on the application of state law and certain requirements of the
Affordable Care Act on all health carriers offering health plans in Minnesota, whether
or not through the Minnesota Insurance Marketplace, to ensure fair competition for all
health carriers in Minnesota, to minimize adverse selection, and to ensure that health
plans are offered in a manner that protects consumers and promotes the provision of
high-quality affordable health care, and improved health outcomes. This chapter contains
the regulatory requirements as specified in Minnesota Statutes, section 62V.05, subdivision
5, paragraph (b), if enacted in 2013 H.F. No. 5/S.F. No. 1 and, upon enactment, shall fully
satisfy the requirements of Minnesota Statutes, section 62V.05, subdivision 5, paragraph
(b), if enacted in 2013 H.F. No. 5/S.F. No. 1.
new text end

new text begin Subd. 2. new text end

new text begin Scope. new text end

new text begin (a) This chapter applies only to health plans offered in the
individual market or the small group market, except short-term coverage as defined in
section 62A.65, subdivision 7.
new text end

new text begin (b) This chapter applies to health carriers with respect to individual health plans and
small group health plans, unless otherwise specified.
new text end

new text begin (c) If a health carrier issues or renews individual or small group health plans in
other states, this chapter applies only to health plans issued or renewed in this state to a
Minnesota resident, or to cover a resident of the state, or issued or renewed to a small
employer that is actively engaged in business in this state, unless otherwise specified.
new text end

new text begin (d) This chapter does not apply to short-term coverage as defined in section 62A.65,
subdivision 7.
new text end

Sec. 3.

new text begin [62K.03] DEFINITIONS.
new text end

new text begin Subdivision 1. new text end

new text begin Applicability. new text end

new text begin For purposes of this chapter, the terms defined in this
section have the meanings given.
new text end

new text begin Subd. 2. new text end

new text begin Affordable Care Act. new text end

new text begin "Affordable Care Act" means the federal Patient
Protection and Affordable Care Act, Public Law 111-148, as amended, including the
federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and
any amendments to it, or guidance and regulations issued under those acts.
new text end

new text begin Subd. 3. new text end

new text begin Dental plan. new text end

new text begin "Dental plan" means a dental plan as defined in section
62Q.76, subdivision 3.
new text end

new text begin Subd. 4. new text end

new text begin Enrollee. new text end

new text begin "Enrollee" means a natural person covered by a health plan and
includes an insured policyholder, subscriber, contract holder, member, covered person,
or certificate holder.
new text end

new text begin Subd. 5. new text end

new text begin Health carrier. new text end

new text begin "Health carrier" means a health carrier as defined in
section 62A.011, subdivision 2.
new text end

new text begin Subd. 6. new text end

new text begin Health plan. new text end

new text begin "Health plan" means a health plan as defined in section
62A.011, subdivision 3.
new text end

new text begin Subd. 7. new text end

new text begin Individual health plan. new text end

new text begin "Individual health plan" means an individual
health plan as defined in section 62A.011, subdivision 4.
new text end

new text begin Subd. 8. new text end

new text begin Minnesota Insurance Marketplace. new text end

new text begin "Minnesota Insurance Marketplace"
means the Minnesota Insurance Marketplace as defined in Minnesota Statutes, section
62V.02, if enacted in 2013 H.F. No. 5/S.F. No. 1.
new text end

new text begin Subd. 9. new text end

new text begin Preferred provider organization. new text end

new text begin "Preferred provider organization"
means a health plan that provides discounts to enrollees or subscribers for services they
receive from certain health care providers.
new text end

new text begin Subd. 10. new text end

new text begin Small group health plan. new text end

new text begin "Small group health plan" means a health plan
issued by a health carrier to a small employer as defined in section 62L.02, subdivision 26.
new text end

new text begin Subd. 11. new text end

new text begin Qualified health plan. new text end

new text begin "Qualified health plan" means a health plan that
meets the definition in section 1301(a) of the Affordable Care Act and has been certified
by the board of the Minnesota Insurance Marketplace in accordance with Minnesota
Statutes, chapter 62V, if enacted in 2013 H.F. No. 5/S.F. No. 1 to be offered through the
Minnesota Insurance Marketplace.
new text end

Sec. 4.

new text begin [62K.04] MARKET RULES; VIOLATION.
new text end

new text begin Subdivision 1. new text end

new text begin Compliance. new text end

new text begin (a) A health carrier issuing an individual health plan
issued to a Minnesota resident or a small group health plan issued to provide coverage to
a small employer that is actively engaged in business in Minnesota shall meet all of the
requirements set forth in this chapter. The failure to meet any of the requirements under
this chapter constitutes a violation of section 72A.20.
new text end

new text begin (b) The requirements of this chapter do not apply to individual or small group health
plans issued before January 1, 2015.
new text end

new text begin (c) The requirements of this chapter do not apply to short-term coverage as defined
in section 62A.65.
new text end

new text begin Subd. 2. new text end

new text begin Penalties. new text end

new text begin In addition to any other penalties provided by the laws of this
state or by federal law, a health carrier or any other person found to have violated any
requirement of this chapter may be subject to the administrative procedures, enforcement
actions, and penalties provided under section 45.027 and chapters 62D and 72A.
new text end

Sec. 5.

new text begin [62K.05] FEDERAL ACT; COMPLIANCE REQUIRED.
new text end

new text begin A health carrier shall comply with all provisions of the Affordable Care Act to
the extent that it imposes a requirement that applies in this state. Compliance with any
provision of the Affordable Care Act is required as of the effective date established for
that provision in the federal act, except as otherwise specifically stated earlier in state law.
new text end

Sec. 6.

new text begin [62K.06] METAL LEVEL MANDATORY OFFERINGS.
new text end

new text begin Subdivision 1. new text end

new text begin Identification. new text end

new text begin A health carrier that offers individual or small group
health plans in Minnesota must provide documentation to the commissioner of commerce
to justify actuarial value levels as specified in section 1302 of the Affordable Care Act for
all individual and small group health plans offered inside and outside of the Minnesota
Insurance Marketplace.
new text end

new text begin Subd. 2. new text end

new text begin Minimum levels. new text end

new text begin (a) A health carrier that offers any individual or small
group health plan, either inside or outside of the Minnesota Insurance Marketplace, must
offer at a minimum a silver level and a gold level health plan to Minnesota residents, as
well as for each health plan offered, a health plan in which the only enrollees are children,
who, as of the beginning of a policy year, have not attained the age of 21 years.
new text end

new text begin (b) A health carrier with less than five percent market share in either the individual
or small group market in Minnesota is exempt from paragraph (a), until January 1, 2020,
unless the health carrier offers a qualified health plan through the Minnesota Insurance
Marketplace. If the health carrier offers a qualified health plan through the Minnesota
Insurance Marketplace, the health carrier must comply with paragraph (a).
new text end

new text begin Subd. 3. new text end

new text begin Minnesota Insurance Marketplace restriction. new text end

new text begin The Minnesota Insurance
Marketplace may not, by contract or otherwise, mandate the types of health plans to be
offered by a health carrier to individuals or small employers purchasing health plans
outside of the Minnesota Insurance Marketplace. For purposes of this section, "health
plan" includes coverage that is excluded under section 62A.011, subdivision 3, clause (6).
new text end

new text begin Subd. 4. new text end

new text begin Metal level defined. new text end

new text begin For purposes of this section, the metal levels are
defined in section 62Q.81, subdivision 1, paragraph (c).
new text end

new text begin Subd. 5. new text end

new text begin Enforcement. new text end

new text begin The commissioner of commerce shall enforce this section.
new text end

Sec. 7.

new text begin [62K.07] INFORMATION DISCLOSURES.
new text end

new text begin (a) A health carrier offering individual or small group health plans must submit the
following information in a format determined by the commissioner of commerce:
new text end

new text begin (1) claims payment policies and practices;
new text end

new text begin (2) periodic financial disclosures;
new text end

new text begin (3) data on enrollment;
new text end

new text begin (4) data on disenrollment;
new text end

new text begin (5) data on the number of claims that are denied;
new text end

new text begin (6) data on rating practices;
new text end

new text begin (7) information on cost-sharing and payments with respect to out-of-network
coverage; and
new text end

new text begin (8) other information required by the secretary of the United States Department of
Health and Human Services under the Affordable Care Act.
new text end

new text begin (b) A health carrier offering an individual or small group health plan must comply
with all information disclosure requirements of all applicable state and federal law,
including the Affordable Care Act. To the extent that both state and federal law impose
information disclosures or standards with respect to a health plan, the health carrier must
comply with the disclosure requirement that provides the greater consumer protection
to Minnesota residents.
new text end

new text begin (c) The commissioner of commerce shall enforce this section.
new text end

Sec. 8.

new text begin [62K.08] MARKETING STANDARDS.
new text end

new text begin Subdivision 1. new text end

new text begin General. new text end

new text begin A health carrier offering individual or small group health
plans must comply with all applicable provisions of the Affordable Care Act, including,
but not limited to, the following:
new text end

new text begin (1) compliance with all state laws pertaining to the marketing of individual or small
group health plans; and
new text end

new text begin (2) establishing marketing practices and benefit designs that will not have the effect of
discouraging the enrollment of individuals with significant health needs in the health plan.
new text end

new text begin Subd. 2. new text end

new text begin Specific requirements. new text end

new text begin (a) Any written marketing materials must include
a statement of enrollee information and rights as described in chapter 62D.
new text end

new text begin (b) Detailed marketing materials must affirmatively disclose all exclusions and
limitations on the services offered.
new text end

new text begin (c) No market materials may lead consumers to believe that all health care needs
will be covered.
new text end

new text begin (d) All marketing materials must contain the following language in bold print: This
health care plan may not cover all your health care expenses, read your contract
carefully to determine which expenses are covered.
new text end

new text begin Subd. 3. new text end

new text begin Enforcement. new text end

new text begin The commissioner of commerce shall enforce this section.
new text end

Sec. 9.

new text begin [62K.09] ACCREDITATION STANDARDS.
new text end

new text begin Subdivision 1. new text end

new text begin Accreditation; general. new text end

new text begin (a) A health carrier that offers any
individual or small group health plans in Minnesota outside of the Minnesota Insurance
Marketplace must be accredited in accordance with this subdivision. A health carrier
must obtain accreditation through URAC, the National Committee for Quality Assurance
(NCQA), or any entity recognized by the United States Department of Health and Human
Services for accreditation of health insurance issuers or health plans by January 1,
2018. Proof of accreditation must be submitted to the commissioner of health in a form
prescribed by the commissioner of health.
new text end

new text begin (b) A health carrier with less than five percent market share in either the individual
or small group market in Minnesota is exempt from this subdivision until January 1, 2020.
new text end

new text begin Subd. 2. new text end

new text begin Accreditation; Minnesota Insurance Marketplace. new text end

new text begin (a) The Minnesota
Insurance Marketplace shall require all health carriers offering a qualified health
plan through the Minnesota Insurance Marketplace to obtain the appropriate level of
accreditation no later than the third year after the first year the health carrier offers a
qualified health plan through the Minnesota Insurance Marketplace. A health carrier
must take the first step of the accreditation process during the first year in which it offers
a qualified health plan. A health carrier that offers a qualified health plan on January 1,
2014, must obtain accreditation by the end of the 2016 plan year.
new text end

new text begin (b) To the extent a health carrier cannot obtain accreditation due to low volume of
enrollees, an exception to this accreditation criterion may be granted by the Minnesota
Insurance Marketplace until such time as the health carrier has a sufficient volume of
enrollees.
new text end

new text begin Subd. 3. new text end

new text begin Enforcement. new text end

new text begin The commissioner of health shall enforce this section.
new text end

Sec. 10.

new text begin [62K.10] GEOGRAPHIC ACCESSIBILITY; PROVIDER NETWORK
ADEQUACY.
new text end

new text begin Subdivision 1. new text end

new text begin Applicability. new text end

new text begin This section applies to all health carriers offering an
individual and small group health plan that designates a network or networks of contracted
providers, or is a preferred provider organization.
new text end

new text begin Subd. 2. new text end

new text begin Primary care; mental health services; general hospital services.
new text end

new text begin Primary care, mental health, and general hospital services must be available to enrollees
within 30 miles or 30 minutes' travel time to the nearest participating or preferred provider.
new text end

new text begin Subd. 3. new text end

new text begin Other health services. new text end

new text begin Specialty physician services, ancillary services,
specialized hospital services, and all other covered health services must be available
to enrollees within 60 miles or 60 minutes' travel time to the nearest participating or
preferred provider.
new text end

new text begin Subd. 4. new text end

new text begin Network adequacy. new text end

new text begin Each designated provider network must include a
sufficient number and type of providers to ensure that covered services are available
to all enrollees without unreasonable delay. In determining network adequacy, the
commissioner of health shall consider availability of services, including the following:
new text end

new text begin (1) primary care physician services are available and accessible 24 hours per day,
seven days per week, within the network area;
new text end

new text begin (2) a sufficient number of primary care physicians have hospital admitting privileges
at one or more participating hospitals within the network area so that necessary admissions
are made on a timely basis consistent with generally accepted practice parameters;
new text end

new text begin (3) specialty physician service is available through the network or contract
arrangement;
new text end

new text begin (4) to the extent that primary care services are provided through primary care
providers other than physicians, and to the extent permitted under applicable scope of
practice in state law for a given provider, these services shall be available and accessible;
and
new text end

new text begin (5) the network has available, either directly or through arrangements, appropriate
and sufficient personnel, physical resources, and equipment to meet the projected needs of
enrollees for covered health care services.
new text end

new text begin Subd. 5. new text end

new text begin Waiver. new text end

new text begin A health carrier or preferred provider organization may apply to
the commissioner of health for a waiver of the requirements in subdivision 2 or 3 if it is
unable to meet the statutory requirements. A waiver application must be made on a form
provided by the commissioner and must demonstrate with specific data that the requirement
of subdivision 2 or 3 is not feasible in a particular service area or part of a service area.
new text end

new text begin Subd. 6. new text end

new text begin Referral centers. new text end

new text begin Subdivisions 2 and 3 shall not apply if an enrollee
is referred to a referral center for health care services. A referral center is a medical
facility that provides highly specialized medical care, including but not limited to organ
transplants and bariatric surgery. A health carrier or preferred provider organization may
consider the volume of services provided annually, case mix, and severity adjusted
mortality and morbidity rates in designating a referral center.
new text end

new text begin Subd. 7. new text end

new text begin Essential community providers. new text end

new text begin Each health carrier must comply with
section 62Q.19 to ensure reasonable and timely access to covered services for low-income,
high-risk, special-needs individuals or those living in a medical shortage area.
new text end

new text begin Subd. 8. new text end

new text begin Enforcement. new text end

new text begin The commissioner of health shall enforce this section.
new text end

Sec. 11.

new text begin [62K.11] BALANCE BILLING PROHIBITED.
new text end

new text begin (a) A network provider is prohibited from billing an enrollee for any amount in
excess of the allowable amount the health carrier has contracted for with the provider
as total payment for the health care service. A network provider is permitted to bill an
enrollee the approved co-payment deductible or coinsurance.
new text end

new text begin (b) A network provider is permitted to bill an enrollee for services not covered by
the enrollee's health plan as long as the enrollee agrees in writing in advance before the
service if performed to pay for the noncovered service.
new text end

Sec. 12.

new text begin [62K.12] QUALITY ASSURANCE AND IMPROVEMENT.
new text end

new text begin (a) All health carriers offering an individual health plan or small group health
plan must have a written internal quality assurance and improvement program that, at a
minimum:
new text end

new text begin (1) provides for ongoing evaluation of the quality of health care provided to its
enrollees;
new text end

new text begin (2) periodically reports the evaluation of the quality of health care to the health
carrier's governing body;
new text end

new text begin (3) follows policies and procedures for the selection and credentialing of network
providers that is consistent with community standards;
new text end

new text begin (4) conducts focused studies directed at problems, potential problems, or areas
with potential for improvements in care;
new text end

new text begin (5) conducts enrollee satisfaction surveys and monitors oral and written complaints
submitted by enrollees or members; and
new text end

new text begin (6) collects and reports Health Effectiveness Data and Information Set (HEDIS)
measures and conducts other quality assessment and improvement activities as directed
by the commissioner of health.
new text end

new text begin (b) The commissioner of health shall submit a report to the chairs and ranking
minority members of senate and house of representatives committees with primary
jurisdiction over commerce and health policy by February 15, 2015, with recommendations
for specific quality assurance and improvement standards for all Minnesota health carriers.
new text end

new text begin (c) The commissioner of health shall enforce this section.
new text end

Sec. 13.

new text begin [62K.13] SERVICE AREA REQUIREMENTS.
new text end

new text begin (a) Health carriers must offer individual and small group health plans in service areas
that are at least the entire geographic area of a county unless serving a smaller geographic
area is necessary, nondiscriminatory, and in the best interest of enrollees. The service area
for any individual or small group health plan must be established without regard to racial,
ethnic, language, or health status-related factors, or other factors that exclude specific
high-utilizing, high-cost, or medically underserved populations.
new text end

new text begin (b) If a health carrier requests to serve less than the entire county, the request
must be made to the commissioner of health on a form and manner determined by the
commissioner and must provide specific data demonstrating that the service area is not
discriminatory, is necessary, and is in the best interest of enrollees.
new text end

Sec. 14.

new text begin [62K.14] NETWORK PROVIDER DIRECTORIES.
new text end

new text begin Health carriers offering qualified health plans through the Minnesota Insurance
Marketplace must submit information on network providers to the Minnesota Insurance
Marketplace. The Minnesota Insurance Marketplace and the commissioner of health must
collaborate to determine the form and manner in which this information shall be provided
to the Minnesota Insurance Marketplace and the commissioner of health. Health carriers
must provide this information at least quarterly and more frequently as determined by the
Minnesota Insurance Marketplace or the commissioner of health.
new text end

Sec. 15.

new text begin [62K.15] LIMITED SCOPE DENTAL PLANS.
new text end

new text begin (a) Limited scope dental plans must be offered on a guaranteed issue basis with
premiums rated on allowable rating factors used for health plans. The commissioner
of commerce shall enforce this paragraph.
new text end

new text begin (b) Limited scope dental plans must ensure dental services are available within 30
miles or 30 minutes' travel time. The commissioner of health shall enforce this paragraph.
new text end

new text begin (c) Health carriers offering limited scope dental plans must comply with this section
and sections 62K.07, 62K.08, 62K.13, and 62K.14.
new text end

Sec. 16.

Minnesota Statutes 2012, section 62Q.19, subdivision 1, is amended to read:

Subdivision 1.

Designation.

(a) 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,
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;

(3) status as a local government unit as defined in section 62D.02, subdivision 11, a
hospital district created or reorganized under sections 447.31 to 447.37, an Indian tribal
government, an Indian health service unit, or a community health board as defined in
chapter 145A;

(4) a former state hospital that specializes in the treatment of cerebral palsy, spina
bifida, epilepsy, closed head injuries, specialized orthopedic problems, and other disabling
conditions;

(5) a sole community hospital. For these rural hospitals, the essential community
provider designation applies to all health services provided, including both inpatient and
outpatient services. For purposes of this section, "sole community hospital" means a
rural hospital that:

(i) is eligible to be classified as a sole community hospital according to Code
of Federal Regulations, title 42, section 412.92, or is 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;

(ii) has experienced net operating income losses in two of the previous three
most recent consecutive hospital fiscal years for which audited financial information is
available; and

(iii) consists of 40 or fewer licensed beds; deleted text begin or
deleted text end

(6) a birth center licensed under section 144.615 deleted text begin . deleted text end new text begin ; or
new text end

new text begin (7) a hospital or hospital system whose inpatients are predominantly under 21 years
of age.
new text end

(b) 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.

(c) 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.

(d) For the purpose of this subdivision, supportive and stabilizing services include at
a minimum, transportation, child care, cultural, and linguistic services where appropriate.