1999 Minnesota Statutes

CHAPTER 62Q. Requirements for health plan companies

     62Q.01 Definitions. 

    Subdivision 1.    Applicability.  For purposes of this 
 chapter, the terms defined in this section have the meanings 
 given. 

    Subd. 2.    Commissioner.  "Commissioner" means the 
 commissioner of health for purposes of regulating health 
 maintenance organizations, and community 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. 

    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. 

    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. 

    Subd. 4.    Health plan company.  "Health plan company" 
 means: 

    (1) a health carrier as defined under section 62A.011, 
 subdivision 2; or 

    (2) a community integrated service network as defined under 
 section 62N.02, subdivision 4a. 

    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; or (3) 
 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.  

    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. 

    HIST: 1994 c 625 art 2 s 14; 1995 c 234 art 2 s 2-6; art 3 s 
 5; 1997 c 225 art 2 s 37-39,62; 1998 c 254 art 1 s 15 

     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. 

    HIST: 1995 c 234 art 2 s 7 

     62Q.021 Federal act; compliance required. 

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

    HIST: 1997 c 175 art 4 s 2 

     62Q.03 Process for defining, developing, and 
  implementing a risk adjustment system. 

    Subdivision 1.    Purpose.  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 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 risk status of those in a given insurance pool; and 
 help maintain the viability of health plan companies, 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.  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. 

    Subd. 2. Repealed, 1995 c 234 art 2 s 36 

    Subd. 3. Repealed, 1995 c 234 art 2 s 36 

    Subd. 4. Repealed, 1995 c 234 art 2 s 36 

    Subd. 5. Repealed, 1995 c 234 art 2 s 36 

    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 public programs 
 risk adjustment work group is governed by section 15.059 for 
 purposes of membership terms, expiration, and removal of 
 members.  The work group shall meet at the discretion of the 
 commissioners of health and human services.  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 programs 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. 

    (e) Before including risk adjustment in a contract for the 
 prepaid medical assistance program, the prepaid general 
 assistance medical care program, or the MinnesotaCare program, 
 the commissioner of human services shall provide to the 
 contractor an analysis of the expected impact on the contractor 
 of the implementation of risk adjustment.  This analysis may be 
 limited by the available data and resources, as determined by 
 the commissioner, and shall not be binding on future contract 
 periods.  This paragraph shall not apply if the contractor has 
 not supplied information to the commissioner related to the risk 
 adjustment analysis. 

    (f) The commissioner of human services shall report to the 
 public program risk adjustment work group on the methodology the 
 department will use for risk adjustment prior to implementation 
 of the risk adjustment payment methodology.  Upon completion of 
 the report to the work group, the commissioner shall phase in 
 risk adjustment according to the following schedule: 

    (1) for the first contract year, no more than ten percent 
 of reimbursements shall be risk adjusted; and 

    (2) for the second contract year, no more than 30 percent 
 of reimbursements shall be risk adjusted. 

    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.  

    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, and 62A.  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. 

    Subd. 7.    Purpose of association.  The association is 
 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. 

    Subd. 8.    Governance.  The association shall be 
 governed according to the plan of operation as established in 
 subdivision 8a. 

    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. 

    Subd. 9.    Data collection and data privacy.  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 that 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. 

    Subd. 10.    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), the directors shall submit for review 
 an appropriate revised plan within 30 days. 

    Subd. 11. Repealed, 1995 c 234 art 2 s 36 

    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. 

    HIST: 1994 c 625 art 2 s 15; 1995 c 234 art 2 s 8-17; 1996 c 
 440 art 1 s 33; 1996 c 451 art 4 s 2; 1997 c 192 s 18; 1997 c 
 225 art 2 s 40; 1998 c 254 art 1 s 16; 1999 c 245 art 2 s 12 

     62Q.07 Action plans. 

    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. 

    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; children 
 with severe emotional disturbance; and persons who are at high 
 risk of requiring treatment.  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 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. 

    HIST: 1994 c 625 art 2 s 16; 1995 c 234 art 2 s 18,19; 1997 c 
 225 art 2 s 62 

     62Q.075 Local public accountability and collaboration 
  plan. 

    Subdivision 1.    Definition.  For purposes of this 
 section, "managed care organization" means a health maintenance 
 organization or community integrated service network. 

    Subd. 2.    Requirement.  Beginning October 31, 1997, 
 all managed care organizations shall file biennially with the 
 action plans required under section 62Q.07 a plan describing the 
 actions the managed care organization has taken and those it 
 intends to take to contribute to achieving public health goals 
 for each service area in which an enrollee of the managed care 
 organization resides.  This plan must be jointly developed in 
 collaboration with the local public health units, and other 
 community organizations providing health services within the 
 same service area as the managed care organization.  Local 
 government units with responsibilities and authority defined 
 under chapters 145A and 256E may designate individuals to 
 participate in the collaborative planning with the managed care 
 organization to provide expertise and represent community needs 
 and goals as identified under chapters 145A and 256E. 

    Subd. 3.    Contents.  The plan must address the 
 following: 

    (a) specific measurement strategies and a description of 
 any activities which contribute to public health goals and needs 
 of high risk and special needs populations as defined and 
 developed under chapters 145A and 256E; 

    (b) description of the process by which the managed care 
 organization will coordinate its activities with the community 
 health boards, and other relevant community organizations 
 servicing the same area; 

    (c) documentation indicating that local public health units 
 and local government unit designees were involved in the 
 development of the plan; 

    (d) documentation of compliance with the plan filed the 
 previous year, including data on the previously identified 
 progress measures. 

    Subd. 4.    Review.  Upon receipt of the plan, the 
 appropriate commissioner shall provide a copy to the 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. 

    HIST: 1994 c 625 art 7 s 1; 1995 c 234 art 8 s 17; 1996 c 451 
 art 4 s 3; 1997 c 225 art 2 s 62; 1999 c 245 art 2 s 13 

  62Q.09 EXPIRED 

     62Q.095 Expanded provider networks. 

    Subdivision 1.    Provider acceptance required.  Each 
 health plan company, with the exception of any health plan 
 company with 50,000 or fewer enrollees in its commercial health 
 plan products and health plan companies that are exempt under 
 subdivision 6, shall establish an expanded network of allied 
 independent health providers, in addition to a preferred 
 network.  A health plan company shall accept as a provider in 
 the expanded network any allied independent health provider 
 who:  (1) meets the health plan company's credentialing 
 standards; (2) agrees to the terms of the health plan company's 
 provider contract; and (3) agrees to comply with all managed 
 care protocols of the health plan company.  A preferred network 
 shall be considered an expanded network if all allied 
 independent health providers who meet the requirements of 
 clauses (1), (2), and (3) are accepted into the preferred 
 network.  A community integrated service network may offer to 
 its enrollees an expanded network of allied independent health 
 providers as described under this section.  

    Subd. 2.    Managed care.  The managed care protocols 
 used by the health plan company may include:  (1) a requirement 
 that an enrollee obtain a referral from the health plan company 
 before obtaining services from an allied independent health 
 provider in the expanded network; (2) limits on the number and 
 length of visits to allied independent health providers in the 
 expanded network allowed by each referral, as long as the number 
 and length of visits allowed is not less than the number and 
 length allowed for comparable referrals to allied independent 
 health providers in the preferred network; and (3) ongoing 
 management and review by the health plan company of the care 
 provided by an allied independent health provider in the 
 expanded network after a referral is made. 

    Subd. 3.    Mandatory offering to enrollees.  (a) Each 
 health plan company shall offer to enrollees the option of 
 receiving covered services through the expanded network of 
 allied independent health providers established under 
 subdivisions 1 and 2.  This expanded network option may be 
 offered as a separate health plan.  The network may establish 
 separate premium rates and cost-sharing requirements for this 
 expanded network plan, as long as these premium rates and 
 cost-sharing requirements are actuarially justified and approved 
 by the commissioner.  This subdivision does not apply to 
 Medicare, medical assistance, general assistance medical care, 
 and MinnesotaCare.  

    (b) Information on this expanded provider network option 
 must be provided by each health plan company during open 
 enrollment and upon enrollment.  

    Subd. 4.    Provider reimbursement.  A health plan 
 company shall pay each allied independent health provider in the 
 expanded network the same rate per unit of service as paid to 
 allied independent health providers in the preferred network. 

    Subd. 5.    Definitions.  (a) For purposes of this 
 section, the following definitions apply. 

    (b) "Allied independent health provider" means an 
 independently enrolled audiologist, chiropractor, dietitian, 
 home health care provider, licensed marriage and family 
 therapist, nurse practitioner or advanced practice nurse, 
 occupational therapist, optometrist, optician, outpatient 
 chemical dependency counselor, pharmacist who is not employed by 
 and based on the premises of a health plan company, physical 
 therapist, podiatrist, licensed psychologist, psychological 
 practitioner, licensed social worker, or speech therapist. 

    (c) "Home health care provider" means a provider of 
 personal care assistance, home health aide, homemaker, respite 
 care, adult day care, or home therapies and home health nursing 
 services. 

    (d) "Independently enrolled" means that a provider can 
 bill, and receive direct payment for services from, a 
 third-party payer or patient. 

    Subd. 6.    Exemption.  A health plan company, to the 
 extent that it operates as a staff model health plan company as 
 defined in section 295.50, subdivision 12b, by employing allied 
 independent health care providers to deliver health care 
 services to enrollees, is exempt from this section.  

    HIST: 1994 c 625 art 1 s 6,18; 1998 c 407 art 2 s 19; 1999 c 
 181 s 5 

     62Q.096 Credentialing of providers. 

    If a health plan company has initially credentialed, as 
 providers in its provider network, individual providers employed 
 by or under contract with an entity that: 

    (1) is authorized to bill under section 256B.0625, 
 subdivision 5; 

    (2) meets the requirements of Minnesota Rules, parts 
 9520.0750 to 9520.0870; 

    (3) is designated an essential community provider under 
 section 62Q.19; and 

    (4) is under contract with the health plan company to 
 provide mental health services, the health plan company must 
 continue to credential at least the same number of providers 
 from that entity, as long as those providers meet the health 
 plan company's credentialing standards.  

 A health plan company shall not refuse to credential these 
 providers on the grounds that their provider network has a 
 sufficient number of providers of that type. 

    HIST: 1998 c 407 art 8 s 4 

     62Q.10 Nondiscrimination. 

    If a health plan company, with the exception of a community 
 integrated service network or an indemnity insurer licensed 
 under chapter 60A who does not offer a product through a 
 preferred provider network, offers coverage of a health care 
 service as part of its plan, it may not deny provider network 
 status to a qualified health care provider type who meets the 
 credentialing requirements of the health plan company solely 
 because the provider is an allied independent health care 
 provider as defined in section 62Q.095. 

    HIST: 1994 c 625 art 1 s 18; art 2 s 18 

  62Q.105 Repealed, 1999 c 239 s 43 

*   NOTE:  Subdivision 1 was also amended by Laws 1999, chapter 
*177, section 56, to read as follows:  

*   "Subdivision 1.    Establishment.  Each health plan 
*company shall establish and make available to enrollees, by July 
*1, 2001, 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."

     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. 

    HIST: 1995 c 234 art 2 s 22 

     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 chapter 45, 
 60A, or 62D.  

    HIST: 1995 c 234 art 2 s 23; 1997 c 225 art 2 s 41; 1999 c 239 
 s 32 

*   NOTE:  The amendment to this section by Laws 1999, chapter 
*239, section 32, is effective April 1, 2000, and applies to 
*contracts issued or renewed on or after that date.  Upon 
*request, the commissioner of health or commerce shall grant an 
*extension of up to three months to any health plan company or 
*utilization review organization that is unable to comply with 
*Laws 1999, chapter 239, sections 1, 3 to 42, and 43, paragraphs 
*(a) and (c) by April 1, 2000, due to circumstances beyond the 
*control of the health plan company or utilization review 
*organization.  Laws 1999, chapter 239, section 44.

     62Q.107 Prohibited provision; judicial review. 

    Beginning January 1, 1999, no health plan, including the 
 coverages described in section 62A.011, subdivision 3, clauses 
 (7) and (10), may specify a standard of review upon which a 
 court may review denial of a claim or of any other decision made 
 by a health plan company with respect to an enrollee.  This 
 section prohibits limiting court review to a determination of 
 whether the health plan company's decision is arbitrary and 
 capricious, an abuse of discretion, or any other standard less 
 favorable to the enrollee than a preponderance of the evidence.  

    HIST: 1998 c 407 art 2 s 21 

  62Q.11 Repealed, 1999 c 239 s 43 

     62Q.12 Denial of access. 

    No health plan company may deny access to a covered health 
 care service unless the denial is made by, or under the 
 direction of, or subject to the review of a health care 
 professional licensed to provide the service in question. 

    HIST: 1994 c 625 art 2 s 20 

     62Q.135 Contracting for chemical dependency services. 

    No health plan company shall contract with a chemical 
 dependency treatment program, unless the program participates in 
 the chemical dependency treatment accountability plan 
 established by the commissioner of human services.  The 
 commissioner of human services shall make data on chemical 
 dependency services and outcomes collected through this program 
 available to health plan companies. 

    HIST: 1994 c 625 art 2 s 21 

     62Q.14 Restrictions on enrollee services. 

    No health plan company may restrict the choice of an 
 enrollee as to where the enrollee receives services related to: 

    (1) the voluntary planning of the conception and bearing of 
 children, provided that this clause does not refer to abortion 
 services; 

    (2) the diagnosis of infertility; 

    (3) the testing and treatment of a sexually transmitted 
 disease; and 

    (4) the testing for AIDS or other HIV-related conditions. 

    HIST: 1994 c 625 art 2 s 22 

     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 144.1495, subdivision 1, and other nonphysician health 
 care professionals must comply with the requirements governing 
 the performance of abortions in section 145.412, subdivision 1. 

    HIST: 1995 c 234 art 2 s 25; 1997 c 183 art 2 s 20 

     62Q.16 Midmonth termination prohibited. 

    The termination of a person's coverage under any health 
 plan as defined in section 62A.011, subdivision 3, with the 
 exception of individual health plans, issued or renewed on or 
 after January 1, 1995, must provide coverage until the end of 
 the month in which coverage was terminated. 

    HIST: 1994 c 625 art 2 s 23 

     62Q.165 Universal coverage. 

    Subdivision 1.    Definition.  It is the commitment of 
 the state to achieve universal health coverage for 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. Repealed, 1997 c 225 art 2 s 63 

    HIST: 1994 c 625 art 6 s 1; 1995 c 234 art 4 s 1 

     62Q.17 Voluntary purchasing pools. 

    Subdivision 1.    Permission to form.  Notwithstanding 
 section 62A.10, employers, groups, and individuals may 
 voluntarily form purchasing pools, solely for the purpose of 
 negotiating and purchasing health plan coverage from health plan 
 companies for members of the pool. 

    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.  

    Subd. 3.    Governing structure.  Each pool must have a 
 governing structure controlled by its members.  The governing 
 structure of the pool is responsible for administration of the 
 pool.  The governing structure shall review and evaluate all 
 bids for coverage from health plan companies, shall determine 
 criteria for joining and leaving the pool, and may design 
 incentives for healthy lifestyles and health promotion programs. 
 The governing structure may design uniform entrance standards 
 for all employers, except small employers as defined under 
 section 62L.02.  Small employers must be permitted to enter any 
 pool if the small employer meets the pool's membership 
 requirements.  Pools must provide as much choice in health plans 
 to members as is financially possible.  The governing structure 
 may charge all members a fee for administrative purposes. 

    Subd. 4.    Enrollment.  Pools must have an annual open 
 enrollment period of not less than 15 days, during which all 
 individuals or groups that qualify for membership may enter the 
 pool without any preexisting condition limitations or exclusions 
 or exclusionary riders, except those permitted under chapter 62L 
 for groups or section 62A.65 for individuals.  Pools must reach 
 and maintain an enrolled population of at least 1,000 members 
 within six months of formation.  If a pool fails to reach or 
 maintain the minimum enrollment, all coverage subsequently 
 purchased through the purchasing pool must be regulated through 
 existing applicable laws and forego all advantages under this 
 section. 

    Subd. 5.    Members.  The governing structure of the 
 pool shall set a minimum time period for membership.  Members 
 must stay in the purchasing pool for the entire minimum period 
 to avoid paying a penalty.  Penalties for early withdrawal from 
 the purchasing pool shall be established by the governing 
 structure. 

    Subd. 6.    Employer-based purchasing pools.  
 Employer-based purchasing pools must, with respect to small 
 employers as defined in section 62L.02, meet all the 
 requirements of chapter 62L.  The experience of the pool must be 
 pooled and the rates blended across all groups.  Pools may 
 decide to create tiers within the pool, based on experience of 
 group members.  These tiers must be designed within the 
 requirements of section 62L.08.  The governing structure may 
 establish criteria limiting movement between tiers.  Tiers must 
 be phased out within two years of the pool's creation. 

    Subd. 7.    Individual members.  Purchasing pools that 
 contain individual members must meet all of the underwriting and 
 rate restrictions found in the individual health plan market. 

    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. 

    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. 

    HIST: 1994 c 625 art 6 s 2; 1995 c 234 art 7 s 24-26 

     62Q.18 Portability of coverage. 

    Subdivision 1.    Definition.  For purposes of this 
 section, 

    (1) "continuous coverage" has the meaning given in section 
 62L.02, subdivision 9; 

    (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; 

    (3) "large employer" means an entity that would be a small 
 employer, as defined in section 62L.02, subdivision 26, except 
 that the entity has more than 50 current employees, based upon 
 the method provided in that subdivision for determining the 
 number of current employees; 

    (4) "preexisting condition" has the meaning given in 
 section 62L.02, subdivision 23; and 

    (5) "qualifying coverage" has the meaning given in section 
 62L.02, subdivision 24. 

    Subd. 2. Repealed, 1995 c 234 art 4 s 4 

    Subd. 3. Repealed, 1995 c 234 art 4 s 4 

    Subd. 4. Repealed, 1995 c 234 art 4 s 4 

    Subd. 5. Repealed, 1995 c 234 art 4 s 4 

    Subd. 6. Repealed, 1995 c 234 art 4 s 4 

    Subd. 7.    Portability of coverage.  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; 

    (2) give full credit for previous continuous coverage 
 against any applicable preexisting condition limitation or 
 preexisting condition exclusion; and 

    (3) with respect to a group health plan offered, sold, 
 issued, or renewed to a large employer, impose preexisting 
 condition limitations or preexisting condition exclusions except 
 to the extent that would be permitted under chapter 62L if the 
 group sponsor were a small employer as defined in section 
 62L.02, subdivision 26. 

    To the extent that this subdivision conflicts with chapter 
 62L, 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. Repealed, 1995 c 234 art 4 s 4 

    Subd. 9. Repealed, 1995 c 234 art 4 s 4 

    HIST: 1994 c 625 art 6 s 3; art 8 s 72; 1995 c 96 s 2; 1995 c 
 234 art 4 s 2; 1997 c 175 art 3 s 1,2; 1997 c 225 art 2 s 63 

     62Q.181 Written certification of coverage. 

    A health plan company shall provide the written 
 certifications of coverage required under United States Code, 
 title 42, sections 300gg(e) and 300gg-43.  This section applies 
 only to coverage that is subject to regulation under state law 
 and only to the extent that the certification of coverage is 
 required under federal law.  The commissioner shall enforce this 
 section. 

    HIST: 1997 c 175 art 4 s 3 

     62Q.185 Guaranteed renewability; large employer group 
  health coverage. 

    (a) No health plan company, as defined in section 62Q.01, 
 subdivision 4, shall refuse to renew a health benefit plan, as 
 defined in section 62L.02, subdivision 15, but issued to a large 
 employer, as defined in section 62Q.18, subdivision 1. 

    (b) This section does not require renewal if: 

    (1) the large employer has failed to pay premiums or 
 contributions as required under the terms of the health benefit 
 plan, or the health plan company has not received timely premium 
 payments unless the late payments were received within a grace 
 period provided under state law; 

    (2) the large employer has performed an act or practice 
 that constitutes fraud or misrepresentation of material fact 
 under the terms of the health benefit plan; 

    (3) the large employer has failed to comply with a material 
 plan provision relating to employer contribution or group 
 participation rules not prohibited by state law; 

    (4) the health plan company is ceasing to offer coverage in 
 the large employer market in this state in compliance with 
 United States Code, title 42, section 300gg-12(c), and 
 applicable state law; 

    (5) in the case of a health maintenance organization, there 
 is no longer any enrollee in the large employer's health benefit 
 plan who lives, resides, or works in the approved service area; 
 or 

    (6) in the case of a health benefit plan made available to 
 large employers only through one or more bona fide associations, 
 the membership of the large employer in the association ceases, 
 but only if such coverage is terminated uniformly without regard 
 to any health-related factor relating to any covered individual. 

    (c) This section does not prohibit a health plan company 
 from modifying the premium rate or from modifying the coverage 
 for purposes of renewal. 

    (d) This section does not require renewal of the coverage 
 of individual enrollees under the health benefit plan if the 
 individual enrollee has performed an act or practice that 
 constitutes fraud or misrepresentation of material fact under 
 the terms of the health benefit plan. 

    HIST: 1997 c 175 art 3 s 3; 1999 c 177 s 57 

     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; 

    (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; or 

    (5) a rural hospital that has qualified for a sole 
 community hospital financial assistance grant in the past three 
 years under section 144.1484, subdivision 1.  For these rural 
 hospitals, the essential community provider designation applies 
 to all health services provided, including both inpatient and 
 outpatient services. 

    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 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 in which the 
 essential community provider is 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 at least 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. 

    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 terminates five years after it is 
 granted, 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.    Rulemaking.  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. 

    HIST: 1994 c 625 art 4 s 6; 1995 c 234 art 2 s 26; 1996 c 451 
 art 2 s 1,2; 1997 c 225 art 2 s 42; 1999 c 239 s 33 

*   NOTE:  The amendment to subdivision 5a by Laws 1999, 
*chapter 239, section 33, is effective April 1, 2000, and applies 
*to contracts issued or renewed on or after that date.  Upon 
*request, the commissioner of health or commerce shall grant an 
*extension of up to three months to any health plan company or 
*utilization review organization that is unable to comply with 
*Laws 1999, chapter 239, sections 1, 3 to 42, and 43, paragraphs 
*(a) and (c) by April 1, 2000, due to circumstances beyond the 
*control of the health plan company or utilization review 
*organization.  Laws 1999, chapter 239, section 44.

  62Q.21 Repealed, 1995 c 234 art 2 s 36 

     62Q.22 Health care services prepaid option. 

    Subdivision 1.    Scope.  A community health clinic that 
 is designated as an essential community provider under section 
 62Q.19 and is associated with a hospital, a governmental unit, 
 or the University of Minnesota may offer to individuals and 
 families the option of purchasing basic health care services on 
 a fixed prepaid basis without satisfying the requirements of 
 chapter 60A, 62A, 62C, or 62D, or any other law or rule that 
 applies to entities licensed under those chapters.  

    Subd. 2.    Registration.  A community health clinic 
 that offers a prepaid option under this section must register on 
 an annual basis with the commissioner of health. 

    Subd. 3.    Premiums.  The premiums for a prepaid option 
 offered under this section must be based on a sliding fee 
 schedule based on current poverty income guidelines.  

    Subd. 4.    Health care services.  (a) A prepaid option 
 offered under this section must provide basic health care 
 services including: 

    (1) services for the diagnosis and treatment of injuries, 
 illnesses, or conditions; 

    (2) child health supervision services up to age 18, as 
 defined under section 62A.047; and 

    (3) preventive health services, including: 

    (i) health education; 

    (ii) health supervision, evaluation, and follow-up; 

    (iii) immunization; and 

    (iv) early disease detection. 

    (b) Inpatient hospital services shall not be offered as a 
 part of a community health clinic's prepaid option.  A clinic 
 may associate with a hospital to provide hospital services to an 
 individual or family who is enrolled in the prepaid option so 
 long as these services are not offered as part of the prepaid 
 option. 

    (c) All health care services included by the community 
 health clinic in a prepaid option must be services that are 
 offered within the scope of practice of the clinic by the 
 clinic's professional staff.  

    Subd. 5.    Guaranteed renewability.  A community health 
 clinic shall not refuse to renew a prepaid option, except for 
 nonpayment of premiums, fraud, or misrepresentation, or as 
 permitted under subdivisions 8 and 9, paragraph (b).  

    Subd. 6.    Information to be provided.  (a) A community 
 health clinic must provide an individual or family who purchases 
 a prepaid option a clear and concise written statement that 
 includes the following information: 

    (1) the health care services that the prepaid option 
 covers; 

    (2) any exclusions or limitations on the health care 
 services offered, including any preexisting condition 
 limitations, cost-sharing arrangements, or prior authorization 
 requirements; 

    (3) where the health care services may be obtained; 

    (4) a description of the clinic's method for resolving 
 patient complaints, including a description of how a patient can 
 file a complaint with the department of health; and 

    (5) a description of the conditions under which the prepaid 
 option may be canceled or terminated. 

    (b) The commissioner of health must approve a copy of the 
 written statement before the community health clinic may offer 
 the prepaid option described in this section.  

    Subd. 7.    Complaint process.  (a) A community health 
 clinic that offers a prepaid option under this section must 
 establish a complaint resolution process.  As an alternative to 
 establishing its own process, a community health clinic may use 
 the complaint process of another organization.  

    (b) A community health clinic must make reasonable efforts 
 to resolve complaints and to inform complainants in writing of 
 the clinic's decision within 60 days of receiving the complaint. 

    (c) A community health clinic that offers a prepaid option 
 under this section must report all complaints that are not 
 resolved within 60 days to the commissioner of health. 

    Subd. 8.    Public assistance program eligibility.  A 
 community health clinic may require an individual or family 
 enrolled in the clinic's prepaid option to apply for medical 
 assistance, general assistance medical care, or the 
 MinnesotaCare program.  The clinic must assist the individual or 
 family in filing the application for the appropriate public 
 program.  If, upon the request of the clinic, an individual or 
 family refuses to apply for these programs, the clinic may 
 disenroll the individual or family from the prepaid option at 
 any time. 

    Subd. 9.    Limitations on enrollment.  (a) A community 
 health clinic may limit enrollment in its prepaid option.  If 
 enrollment is limited, a waiting list must be established. 

    (b) A community health clinic may deny enrollment in its 
 prepaid option to an individual or family whose gross family 
 income is greater than 275 percent of the federal poverty 
 guidelines. 

    (c) No community health clinic may restrict or deny 
 enrollment in its prepaid option because of an individual's or a 
 family's financial limitations, except as permitted under this 
 subdivision. 

    HIST: 1997 c 194 s 1 

     62Q.23 General services. 

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

    (b) Health plan companies shall comply with sections 
 62A.047, 62A.27, and any other coverage required under chapter 
 62A of newborn infants, dependent children who do not reside 
 with a covered person, handicapped children and dependents, and 
 adopted children.  A health plan company providing dependent 
 coverage shall comply with section 62A.302. 

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

    HIST: 1994 c 625 art 4 s 8 

  62Q.25 Repealed, 1997 c 225 art 2 s 63 

  62Q.27 Repealed, 1995 c 234 art 2 s 36 

  62Q.29 Repealed, 1997 c 225 art 2 s 63 

  62Q.30 Repealed, 1999 c 239 s 43 

*   NOTE:  This section was also amended by Laws 1999, chapter 
*177, section 58, to read as follows:  

*   "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 health 
*plan companies with contested treatment, coverage, and service 
*issues to be in effect July 1, 2001.  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 a health plan 
*company that is the subject of repeated orders by the 
*commissioner that suggests a pattern of inappropriate 
*underutilization."

     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. 

    HIST: 1994 c 625 art 7 s 2; 1995 c 234 art 8 s 18 

     62Q.33 Local government public health functions. 

    Subdivision 1.    Findings.  The legislature finds that 
 the local government public health functions of community 
 assessment, policy development, and assurance of service 
 delivery are essential elements in consumer protection and in 
 achieving the objectives of health care reform in Minnesota.  
 The legislature further finds that the site-based and 
 population-based services provided by state and local health 
 departments are a critical strategy for the long-term 
 containment of health care costs.  The legislature further finds 
 that without adequate resources, the local government public 
 health system will lack the capacity to fulfill these functions 
 in a manner consistent with the needs of a reformed health care 
 delivery system. 

    Subd. 2.    Report on system development.  The 
 commissioner of health, in consultation with the state community 
 health services advisory committee and the commissioner of human 
 services, and representatives of local health departments, 
 county government, a municipal government acting as a local 
 board of health, area Indian health services, health care 
 providers, and citizens concerned about public health, shall 
 coordinate the process for defining implementation and financing 
 responsibilities of the local government core public health 
 functions.  The commissioner shall submit recommendations and an 
 initial and final report on local government core public health 
 functions according to the timeline established in subdivision 5.

    Subd. 3.    Core public health functions.  (a) The 
 report required by subdivision 2 must describe the local 
 government core public health functions of:  assessment of 
 community health needs; goal-determination, public policy, and 
 program development for addressing these needs; and assurance of 
 service availability and accessibility to meet community health 
 goals and needs.  The report must further describe activities 
 for implementation of these functions that are the continuing 
 responsibility of the local government public health system, 
 taking into account the ongoing reform of the health care 
 delivery system. 

    (b) The activities to be defined in terms of the local 
 government core public health functions include, but are not 
 limited to: 

    (1) consumer protection and advocacy; 

    (2) targeted outreach and linkage to personal services; 

    (3) health status monitoring and disease surveillance; 

    (4) investigation and control of diseases and injuries; 

    (5) protection of the environment, work places, housing, 
 food, and water; 

    (6) laboratory services to support disease control and 
 environmental protection; 

    (7) health education and information; 

    (8) community mobilization for health-related issues; 

    (9) training and education of public health professionals; 

    (10) public health leadership and administration; 

    (11) emergency medical services; 

    (12) violence prevention; and 

    (13) other activities that have the potential to improve 
 the health of the population or special needs populations and 
 reduce the need for or cost of health care services. 

    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 
 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. 

    Subd. 5.    Timeline.  (a) By January 15, 1996, the 
 commissioner 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. 

    (b) By January 15, 1997, and by January 15 of each 
 odd-numbered year thereafter, the commissioner shall present to 
 the legislature an updated report and recommendations. 

    HIST: 1994 c 625 art 7 s 3; 1995 c 234 art 8 s 19,20; 1997 c 
 225 art 2 s 43 

  62Q.41 Repealed, 1997 c 225 art 2 s 63 

     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. 

    HIST: 1995 c 234 art 2 s 27 

     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; or 

    (3) 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.  

    HIST: 1995 c 234 art 2 s 28; 1997 c 225 art 2 s 44 

     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. 

    HIST: 1995 c 234 art 2 s 29 

     62Q.49 Enrollee cost sharing; negotiated provider 
  payments. 

    Subdivision 1.    Applicability.  This section applies 
 to all health plans, as defined in section 62Q.01, subdivision 
 3, that provide coverage for health care to be provided entirely 
 or partially: 

    (1) through contracts in which health care providers agree 
 to accept discounted charges, negotiated charges, or other 
 limits on health care provider charges; 

    (2) by employees of, or facilities or entities owned by, 
 the issuer of the health plan; or 

    (3) through contracts with health care providers that 
 provide for payment to the providers on a fully or partially 
 capitated basis or on any other non-fee-for-service basis. 

    Subd. 2.    Disclosure required.  (a) All health plans 
 included in subdivision 1 must clearly specify how the cost of 
 health care used to calculate any copayments, coinsurance, or 
 lifetime benefits will be affected by the arrangements described 
 in subdivision 1. 

    (b) Any summary or other marketing material used in 
 connection with marketing of a health plan that is subject to 
 this section must prominently disclose and clearly explain the 
 provisions required under paragraph (a), if the summary or other 
 marketing material refers to copayments, coinsurance, or maximum 
 lifetime benefits. 

    (c) A health plan that is subject to paragraph (a) must not 
 be used in this state if the commissioner of commerce or health, 
 as appropriate, has determined that it does not comply with this 
 section. 

    HIST: 1996 c 446 art 1 s 50 

     62Q.50 Prostate cancer screening. 

    A health plan must cover prostate cancer screening for men 
 40 years of age or over who are symptomatic or in a high-risk 
 category and for all men 50 years of age or older. 

    The screening must consist at a minimum of a 
 prostate-specific antigen blood test and a digital rectal 
 examination. 

    This coverage is subject to any deductible, coinsurance, 
 copayment, or other limitation on coverage applicable to other 
 coverages under the plan. 

    For purposes of this section, "health plan" includes 
 coverage that is excluded under section 62A.011, subdivision 3, 
 clauses (7) and (10). 

    HIST: 1996 c 446 art 1 s 51,72,73; 1998 c 339 s 12 

     62Q.51 Point-of-service option. 

    Subdivision 1.    Definition.  For purposes for this 
 section, "point-of-service option" means a health plan under 
 which the health plan company will reimburse an appropriately 
 licensed or registered provider for providing covered services 
 to an enrollee, without regard to whether the provider belongs 
 to a particular network and without regard to whether the 
 enrollee was referred to the provider by another provider.  

    Subd. 2.    Required point-of-service option.  Each 
 health plan company operating in the small group or large group 
 market shall offer at least one point-of-service option in each 
 such market in which it operates. 

    Subd. 3.    Rate approval.  The premium rates and cost 
 sharing requirements for each option must be submitted to the 
 commissioner of health or the commissioner of commerce as 
 required by law.  A health plan that includes lower enrollee 
 cost sharing for services provided by network providers than for 
 services provided by out-of-network providers, or lower enrollee 
 cost sharing for services provided with prior authorization or 
 second opinion than for services provided without prior 
 authorization or second opinion, qualifies as a point-of-service 
 option. 

    Subd. 4.    Exemption.  This section does not apply to a 
 health plan company with fewer than 50,000 enrollees in its 
 commercial health plan products. 

    HIST: 1996 c 446 art 1 s 52; 1999 c 181 s 6 

     62Q.52 Direct access to obstetric and gynecologic 
  services. 

    (a) Health plan companies shall allow female enrollees 
 direct access to obstetricians and gynecologists for the 
 following services: 

    (1) annual preventive health examinations, which shall 
 include a gynecologic examination, and any subsequent obstetric 
 or gynecologic visits determined to be medically necessary by 
 the examining obstetrician or gynecologist, based upon the 
 findings of the examination; 

    (2) maternity care; and 

    (3) evaluation and necessary treatment for acute 
 gynecologic conditions or emergencies. 

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

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

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

    HIST: 1997 c 26 s 1 

     62Q.525 Coverage for off-label drug use. 

    Subdivision 1.    Scope of coverage.  This section 
 applies to all health plans, including the coverages described 
 in section 62A.011, subdivision 3, clauses (7) and (10), that 
 are issued or renewed to a Minnesota resident.  

    Subd. 2.    Definitions.  (a) For purposes of this 
 section, the terms defined in this subdivision have the meanings 
 given them.  

    (b) "Medical literature" means articles from major peer 
 reviewed medical journals that have recognized the drug or 
 combination of drugs' safety and effectiveness for treatment of 
 the indication for which it has been prescribed.  Each article 
 shall meet the uniform requirements for manuscripts submitted to 
 biomedical journals established by the international committee 
 of medical journal editors or be published in a journal 
 specified by the United States Secretary of Health and Human 
 Services pursuant to United States Code, title 42, section 
 1395x, paragraph (t), clause (2), item (B), as amended, as 
 acceptable peer review medical literature.  Each article must 
 use generally acceptable scientific standards and must not use 
 case reports to satisfy this criterion. 

    (c) "Off-label use of drugs" means when drugs are 
 prescribed for treatments other than those stated in the 
 labeling approved by the federal Food and Drug Administration.  

    (d) "Standard reference compendia" means:  

    (1) the United States Pharmacopeia Drug Information; or 

    (2) the American Hospital Formulary Service Drug 
 Information. 

    Subd. 3.    Required coverage.  (a) Every type of 
 coverage included in subdivision 1 that provides coverage for 
 drugs may not exclude coverage of a drug for the treatment of 
 cancer on the ground that the drug has not been approved by the 
 federal Food and Drug Administration for the treatment of cancer 
 if the drug is recognized for treatment of cancer in one of the 
 standard reference compendia or in one article in the medical 
 literature, as defined in subdivision 2.  

    (b) Coverage of a drug required by this subdivision 
 includes coverage of medically necessary services directly 
 related to and required for appropriate administration of the 
 drug.  

    (c) Coverage required by this subdivision does not include 
 coverage of a drug not listed on the formulary of the coverage 
 included in subdivision 1. 

    (d) Coverage of a drug required under this subdivision must 
 not be subject to any copayment, coinsurance, deductible, or 
 other enrollee cost-sharing greater than the coverage included 
 in subdivision 1 applies to other drugs. 

    (e) The commissioner of commerce or health, as appropriate, 
 may direct a person that issues coverage included in subdivision 
 1 to make payments required by this section.  

    Subd. 4.    Construction.  This section must not be 
 construed to:  

    (1) alter existing law limiting the coverage of drugs that 
 have not been approved by the federal Food and Drug 
 Administration; 

    (2) require coverage for any drug when the federal Food and 
 Drug Administration has determined its use to be 
 contraindicated; 

    (3) require coverage for experimental drugs not otherwise 
 approved for any indication by the federal Food and Drug 
 Administration; or 

    (4) reduce or limit coverage for off-label use of drugs 
 otherwise required by law or contract. 

    HIST: 1998 c 301 s 1 

     62Q.53 Mental health coverage; minimum standards for 
  medically necessary care. 

    Subdivision 1.    Requirement.  No health plan that 
 covers mental health services may be offered, sold, issued, or 
 renewed in this state that requires mental health services to 
 satisfy a definition of "medically necessary care," "medical 
 necessity," or similar term that is more restrictive with 
 respect to mental health than the definition provided in 
 subdivision 2. 

    Subd. 2.    Minimum definition.  "Medically necessary 
 care" means health care services appropriate, in terms of type, 
 frequency, level, setting, and duration, to the enrollee's 
 diagnosis or condition, and diagnostic testing and preventive 
 services.  Medically necessary care must be consistent with 
 generally accepted practice parameters as determined by health 
 care providers in the same or similar general specialty as 
 typically manages the condition, procedure, or treatment at 
 issue and must: 

    (1) help restore or maintain the enrollee's health; or 

    (2) prevent deterioration of the enrollee's condition.  

    Subd. 3.    Health plan; definition.  For purposes of 
 this section, "health plan" has the meaning given in section 
 62Q.01, subdivision 3, but includes the coverages listed in 
 section 62A.011, subdivision 3, clauses (7) and (10). 

    HIST: 1997 c 49 s 1 

     62Q.54 Referrals for residents of health care facilities.

    If an enrollee is a resident of a health care facility 
 licensed under chapter 144A or a housing with services 
 establishment registered under chapter 144D, the enrollee's 
 primary care physician must refer the enrollee to that 
 facility's skilled nursing unit or that facility's appropriate 
 care setting, provided that the health plan company and the 
 provider can best meet the patient's needs in that setting, if 
 the following conditions are met: 

    (1) the facility agrees to be reimbursed at that health 
 plan company's contract rate negotiated with similar providers 
 for the same services and supplies; and 

    (2) the facility meets all guidelines established by the 
 health plan company related to quality of care, utilization, 
 referral authorization, risk assumption, use of health plan 
 company network, and other criteria applicable to providers 
 under contract for the same services and supplies. 

    HIST: 1997 c 225 art 2 s 45 

     62Q.55 Emergency services. 

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

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

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

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

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

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

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

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

    HIST: 1997 c 237 s 11 

     62Q.56 Continuity of care. 

    Subdivision 1.    Change in health care provider.  (a) 
 If enrollees are required to access services through selected 
 primary care providers for coverage, the health plan company 
 shall prepare a written plan that provides for continuity of 
 care in the event of contract termination between the health 
 plan company and any of the contracted primary care providers or 
 general hospital providers.  The written plan must explain: 

    (1) how the health plan company will inform affected 
 enrollees, insureds, or beneficiaries about termination at least 
 30 days before the termination is effective, if the health plan 
 company or health care network cooperative has received at least 
 120 days' prior notice; 

    (2) how the health plan company will inform the affected 
 enrollees about what other participating providers are available 
 to assume care and how it will facilitate an orderly transfer of 
 its enrollees from the terminating provider to the new provider 
 to maintain continuity of care; 

    (3) the procedures by which enrollees will be transferred 
 to other participating providers, when special medical needs, 
 special risks, or other special circumstances, such as cultural 
 or language barriers, require them to have a longer transition 
 period or be transferred to nonparticipating providers; 

    (4) who will identify enrollees with special medical needs 
 or at special risk and what criteria will be used for this 
 determination; and 

    (5) how continuity of care will be provided for enrollees 
 identified as having special needs or at special risk, and 
 whether the health plan company has assigned this responsibility 
 to its contracted primary care providers. 

    (b) If the contract termination was not for cause, 
 enrollees can request a referral to the terminating provider for 
 up to 120 days if they have special medical needs or have other 
 special circumstances, such as cultural or language barriers.  
 The health plan company can require medical records and other 
 supporting documentation in support of the requested referral.  
 Each request for referral to a terminating provider shall be 
 considered by the health plan company on a case-by-case basis. 

    (c) If the contract termination was for cause, enrollees 
 must be notified of the change and transferred to participating 
 providers in a timely manner so that health care services remain 
 available and accessible to the affected enrollees.  The health 
 plan company is not required to refer an enrollee back to the 
 terminating provider if the termination was for cause. 

    Subd. 2.    Change in health plans.  (a) The health plan 
 company shall prepare a written plan that provides a process for 
 coverage determinations for continuity of care for new enrollees 
 with special needs, special risks, or other special 
 circumstances, such as cultural or language barriers, who 
 request continuity of care with their former provider for up to 
 120 days.  The written plan must explain the criteria that will 
 be used for determining special needs cases, and how continuity 
 of care will be provided. 

    (b) This subdivision applies only to group coverage and 
 continuation and conversion coverage, and applies only to 
 changes in health plans made by the employer. 

    Subd. 3.    Disclosures.  The written plans required 
 under this section must be made available upon request to 
 enrollees or prospective enrollees. 

    HIST: 1997 c 237 s 12 

     62Q.58 Access to specialty care. 

    Subdivision 1.    Standing referral.  A health plan 
 company shall establish a procedure by which an enrollee may 
 apply for a standing referral to a health care provider who is a 
 specialist if a referral to a specialist is required for 
 coverage.  This procedure for a standing referral must specify 
 the necessary criteria and conditions, which must be met in 
 order for an enrollee to obtain a standing referral. 

    Subd. 2.    Coordination of services.  A primary care 
 provider or primary care group shall remain responsible for 
 coordinating the care of an enrollee who has received a standing 
 referral to a specialist.  The specialist shall not make any 
 secondary referrals related to primary care services without 
 prior approval by the primary care provider or primary care 
 group.  However, an enrollee with a standing referral to a 
 specialist may request primary care services from that 
 specialist.  The specialist, in agreement with the enrollee and 
 primary care provider or primary care group, may elect to 
 provide primary care services to that enrollee according to 
 procedures established by the health plan company.  

    Subd. 3.    Disclosure.  Information regarding referral 
 procedures must be included in member contracts or certificates 
 of coverage and must be provided to an enrollee or prospective 
 enrollee by a health plan company upon request. 

    HIST: 1997 c 237 s 13 

     62Q.64 Disclosure of executive compensation. 

    (a) Each health plan company doing business in this state 
 shall annually file with the consumer advisory board created in 
 section 62J.75: 

    (1) a copy of the health plan company's form 990 filed with 
 the federal Internal Revenue Service; or 

    (2) if the health plan company did not file a form 990 with 
 the federal Internal Revenue Service, a list of the amount and 
 recipients of the health plan company's five highest salaries, 
 including all types of compensation, in excess of $50,000. 

    (b) A filing under this section is public data under 
 section 13.03. 

    HIST: 1997 c 237 s 14 

     62Q.65 Access to provider discounts. 

    Subdivision 1.    Requirement.  A high deductible health 
 plan must, when used in connection with a medical savings 
 account, provide the enrollee access to any discounted provider 
 fees for services covered by the high deductible health plan, 
 regardless of whether the enrollee has satisfied the deductible 
 for the high deductible health plan. 

    Subd. 2.    Definitions.  For purposes of this section, 
 the following terms have the meanings given: 

    (1) "high deductible health plan" has the meaning given 
 under the Internal Revenue Code of 1986, section 220(c)(2); 

    (2) "medical savings account" has the meaning given under 
 the Internal Revenue Code of 1986, section 220(d)(1); and 

    (3) "discounted provider fees" means fees contained in a 
 provider agreement entered into by the issuer of the high 
 deductible health plan, or an affiliate of the issuer, for use 
 in connection with the high deductible health plan. 

    HIST: 1997 c 225 art 2 s 46 

     62Q.66 Durable medical equipment coverage. 

    No health plan company that covers durable medical 
 equipment may utilize medical coverage criteria for durable 
 medical equipment that limits coverage solely to equipment used 
 in the home. 

    HIST: 1998 c 334 s 1 

     62Q.67 Disclosure of covered durable medical equipment. 

    Subdivision 1.    Disclosure.  A health plan company 
 that covers durable medical equipment shall provide enrollees, 
 and upon request prospective enrollees, written disclosure that 
 includes the information set forth in subdivision 2.  The health 
 plan company may include the information in the member contract, 
 certificate of coverage, schedule of payments, member handbook, 
 or other written enrollee communication. 

    Subd. 2.    Information to be disclosed.  A health plan 
 company that covers durable medical equipment shall disclose the 
 following information: 

    (a) general descriptions of the coverage for durable 
 medical equipment, level of coverage available, and criteria and 
 procedures for any required prior authorizations; and 

    (b) the address and telephone number of a health plan 
 representative whom an enrollee may contact to obtain specific 
 information verbally, or upon request in writing, about prior 
 authorization including criteria used in making coverage 
 decisions and information on limitations or exclusions for 
 durable medical equipment. 

    HIST: 1998 c 334 s 2 

     62Q.68 Definitions. 

    Subdivision 1.    Application.  For purposes of sections 
 62Q.68 to 62Q.72, the terms defined in this section have the 
 meanings given them.  For purposes of sections 62Q.69 and 
 62Q.70, the term "health plan company" does not include an 
 insurance company licensed under chapter 60A to offer, sell, or 
 issue a policy of accident and sickness insurance as defined in 
 section 62A.01 or a nonprofit health service plan corporation 
 regulated under chapter 62C that only provides dental coverage 
 or vision coverage. 

    Subd. 2.    Complaint.  "Complaint" means any grievance 
 against a health plan company that is not the subject of 
 litigation and that has been submitted by a complainant to a 
 health plan company regarding the provision of health services 
 including, but not limited to, the scope of coverage for health 
 care services; retrospective denials or limitations of payment 
 for services; eligibility issues; denials, cancellations, or 
 nonrenewals of coverage; administrative operations; and the 
 quality, timeliness, and appropriateness of health care services 
 rendered.  If the complaint is from an applicant, the complaint 
 must relate to the application.  If the complaint is from a 
 former enrollee, the complaint must relate to services received 
 during the period of time the individual was an enrollee.  Any 
 grievance requiring a medical determination in its resolution 
 must have the medical determination aspect of the complaint 
 processed under the appeal procedure described in section 62M.06.

    Subd. 3.    Complainant.  "Complainant" means an 
 enrollee, applicant, or former enrollee, or anyone acting on 
 behalf of an enrollee, applicant, or former enrollee, who 
 submits a complaint. 

    HIST: 1999 c 239 s 34 

*   NOTE:  This section, as added by Laws 1999, chapter 239, 
*section 34, is effective April 1, 2000, and applies to contracts 
*issued or renewed on or after that date.  Upon request, the 
*commissioner of health or commerce shall grant an extension of 
*up to three months to any health plan company or utilization 
*review organization that is unable to comply with Laws 1999, 
*chapter 239, sections 1, 3 to 42, and 43, paragraphs (a) and (c) 
*by April 1, 2000, due to circumstances beyond the control of the 
*health plan company or utilization review organization.  Laws 
*1999, chapter 239, section 44.

     62Q.69 Complaint resolution. 

    Subdivision 1.    Establishment.  Each health plan 
 company must establish and maintain an internal complaint 
 resolution process that meets the requirements of this section 
 to provide for the resolution of a complaint initiated by a 
 complainant. 

    Subd. 2.    Procedures for filing a complaint.  (a) A 
 complainant may submit a complaint to a health plan company 
 either by telephone or in writing.  If a complaint is submitted 
 orally and the resolution of the complaint, as determined by the 
 complainant, is partially or wholly adverse to the complainant, 
 or the oral complaint is not resolved to the satisfaction of the 
 complainant, by the health plan company within ten days of 
 receiving the complaint, the health plan company must inform the 
 complainant that the complaint may be submitted in writing.  The 
 health plan company must also offer to provide the complainant 
 with any assistance needed to submit a written complaint, 
 including an offer to complete the complaint form for a 
 complaint that was previously submitted orally and promptly mail 
 the completed form to the complainant for the complainant's 
 signature.  At the complainant's request, the health plan 
 company must provide the assistance requested by the 
 complainant.  The complaint form must include the following 
 information: 

    (1) the telephone number of the office of health care 
 consumer assistance, advocacy, and information, and the health 
 plan company member services or other departments or persons 
 equipped to advise complainants on complaint resolution; 

    (2) the address to which the form must be sent; 

    (3) a description of the health plan company's internal 
 complaint procedure and the applicable time limits; and 

    (4) the toll-free telephone number of either the 
 commissioner of health or commerce and notification that the 
 complainant has the right to submit the complaint at any time to 
 the appropriate commissioner for investigation. 

    (b) Upon receipt of a written complaint, the health plan 
 company must notify the complainant within ten business days 
 that the complaint was received, unless the complaint is 
 resolved to the satisfaction of the complainant within the ten 
 business days. 

    (c) Each health plan company must provide, in the member 
 handbook, subscriber contract, or certification of coverage, a 
 clear and concise description of how to submit a complaint and a 
 statement that, upon request, assistance in submitting a written 
 complaint is available from the health plan company. 

    Subd. 3.    Notification of complaint decisions.  (a) 
 The health plan company must notify the complainant in writing 
 of its decision and the reasons for it as soon as practical but 
 in no case later than 30 days after receipt of a written 
 complaint. If the health plan company cannot make a decision 
 within 30 days due to circumstances outside the control of the 
 health plan company, the health plan company may take up to 14 
 additional days to notify the complainant of its decision.  If 
 the health plan company takes any additional days beyond the 
 initial 30-day period to make its decision, it must inform the 
 complainant, in advance, of the extension and the reasons for 
 the extension.  

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

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

    HIST: 1999 c 239 s 35 

*   NOTE:  This section, as added by Laws 1999, chapter 239, 
*section 35, is effective April 1, 2000, and applies to contracts 
*issued or renewed on or after that date.  Upon request, the 
*commissioner of health or commerce shall grant an extension of 
*up to three months to any health plan company or utilization 
*review organization that is unable to comply with Laws 1999, 
*chapter 239, sections 1, 3 to 42, and 43, paragraphs (a) and (c) 
*by April 1, 2000, due to circumstances beyond the control of the 
*health plan company or utilization review organization.  Laws 
*1999, chapter 239, section 44.

     62Q.70 Appeal of the complaint decision. 

    Subdivision 1.    Establishment.  (a) Each health plan 
 company shall establish an internal appeal process for reviewing 
 a health plan company's decision regarding a complaint filed in 
 accordance with section 62Q.69.  The appeal process must meet 
 the requirements of this section.  

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

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

    Subd. 2.    Procedures for filing an appeal.  If a 
 complainant notifies the health plan company of the 
 complainant's desire to appeal the health plan company's 
 decision regarding the complaint through the internal appeal 
 process, the health plan company must provide the complainant 
 the option for the appeal to occur either in writing or by 
 hearing. 

    Subd. 3.    Notification of appeal decisions.  (a) If a 
 complainant appeals in writing, the health plan company must 
 give the complainant written notice of the appeal decision and 
 all key findings within 30 days of the health plan company's 
 receipt of the complainant's written notice of appeal.  If a 
 complainant appeals by hearing, the health plan company must 
 give the complainant written notice of the appeal decision and 
 all key findings within 45 days of the health plan company's 
 receipt of the complainant's written notice of appeal. 

    (b) If the appeal decision is partially or wholly adverse 
 to the complainant, the notice must advise the complainant of 
 the right to submit the appeal decision to the external review 
 process described in section 62Q.73 and the procedure for 
 initiating the external process. 

    (c) Upon the request of the complainant, the health plan 
 company must provide the complainant with a complete summary of 
 the appeal decision.  

    HIST: 1999 c 239 s 36 

*   NOTE:  This section, as added by Laws 1999, chapter 239, 
*section 36, is effective April 1, 2000, and applies to contracts 
*issued or renewed on or after that date.  Upon request, the 
*commissioner of health or commerce shall grant an extension of 
*up to three months to any health plan company or utilization 
*review organization that is unable to comply with Laws 1999, 
*chapter 239, sections 1, 3 to 42, and 43, paragraphs (a) and (c) 
*by April 1, 2000, due to circumstances beyond the control of the 
*health plan company or utilization review organization.  Laws 
*1999, chapter 239, section 44.

     62Q.71 Notice to enrollees. 

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

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

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

    (3) how to request an appeal either through the procedures 
 described in sections 62Q.69 and 62Q.70 or through the 
 procedures described in chapter 62M; 

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

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

    (6) of the telephone number of the office of consumer 
 assistance, advocacy, and information; and 

    (7) of the right to obtain an external review under section 
 62Q.73 and a description of when and how that right may be 
 exercised. 

    HIST: 1999 c 239 s 37 

*   NOTE:  This section, as added by Laws 1999, chapter 239, 
*section 37, is effective April 1, 2000, and applies to contracts 
*issued or renewed on or after that date.  Upon request, the 
*commissioner of health or commerce shall grant an extension of 
*up to three months to any health plan company or utilization 
*review organization that is unable to comply with Laws 1999, 
*chapter 239, sections 1, 3 to 42, and 43, paragraphs (a) and (c) 
*by April 1, 2000, due to circumstances beyond the control of the 
*health plan company or utilization review organization.  Laws 
*1999, chapter 239, section 44.

     62Q.72 Recordkeeping; reporting. 

    Subdivision 1.    Recordkeeping.  Each health plan 
 company shall maintain records of all enrollee complaints and 
 their resolutions.  These records shall be retained for five 
 years and shall be made available to the appropriate 
 commissioner upon request.  An insurance company licensed under 
 chapter 60A may instead comply with section 72A.20, subdivision 
 30. 

    Subd. 2.    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, or 30 business days as provided 
 under section 72A.201, subdivision 4, clause (3), for insurance 
 companies licensed under chapter 60A.  The commissioner shall 
 also make this information available to the public upon request. 

    HIST: 1999 c 239 s 38 

*   NOTE:  This section, as added by Laws 1999, chapter 239, 
*section 38, is effective April 1, 2000, and applies to contracts 
*issued or renewed on or after that date.  Upon request, the 
*commissioner of health or commerce shall grant an extension of 
*up to three months to any health plan company or utilization 
*review organization that is unable to comply with Laws 1999, 
*chapter 239, sections 1, 3 to 42, and 43, paragraphs (a) and (c) 
*by April 1, 2000, due to circumstances beyond the control of the 
*health plan company or utilization review organization.  Laws 
*1999, chapter 239, section 44.

     62Q.73 External review of adverse determinations. 

    Subdivision 1.    Definition.  For purposes of this 
 section, "adverse determination" means:  

    (1) a complaint decision relating to a health care service 
 or claim that has been appealed in accordance with section 
 62Q.70 and the appeal decision is partially or wholly adverse to 
 the complainant; 

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

    (3) a decision relating to a health care service made by a 
 health plan company licensed under chapter 60A that denies the 
 service on the basis that the service was not medically 
 necessary. 

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

    Subd. 2.    Exception.  (a) This section does not apply 
 to governmental programs except as permitted under paragraph (b).
 For purposes of this subdivision, "governmental programs" means 
 the prepaid medical assistance program, the MinnesotaCare 
 program, the prepaid general assistance medical care program, 
 and the federal Medicare program. 

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

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

    Subd. 3.    Right to external review.  (a) Any enrollee 
 or anyone acting on behalf of an enrollee who has received an 
 adverse determination may submit a written request for an 
 external review of the adverse determination, if applicable 
 under section 62Q.68, subdivision 1, or 62M.06, to the 
 commissioner of health if the request involves a health plan 
 company regulated by that commissioner or to the commissioner of 
 commerce if the request involves a health plan company regulated 
 by that commissioner.  The written request must be accompanied 
 by a filing fee of $25.  The fee may be waived by the 
 commissioner of health or commerce in cases of financial 
 hardship. 

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

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

    Subd. 4.    Contract.  Pursuant to a request for 
 proposal, the commissioner of administration, in consultation 
 with the commissioners of health and commerce, shall contract 
 with an organization or business entity to provide independent 
 external reviews of all adverse determinations submitted for 
 external review.  The contract shall ensure that the fees for 
 services rendered in connection with the reviews be reasonable. 

    Subd. 5.    Criteria.  (a) The request for proposal must 
 require that the entity demonstrate: 

    (1) no conflicts of interest in that it is not owned, a 
 subsidiary of, or affiliated with a health plan company or 
 utilization review organization; 

    (2) an expertise in dispute resolution; 

    (3) an expertise in health-related law; 

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

    (5) an ability to provide data to the commissioners of 
 health and commerce on reviews conducted; and 

    (6) an ability to ensure confidentiality of medical records 
 and other enrollee information. 

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

    Subd. 6.    Process.  (a) Upon receiving a request for 
 an external review, the external review entity must provide 
 immediate notice of the review to the enrollee and to the health 
 plan company.  Within ten business days of receiving notice of 
 the review, the health plan company and the enrollee must 
 provide the external review entity with any information that 
 they wish to be considered.  Each party shall be provided an 
 opportunity to present its version of the facts and arguments.  
 An enrollee may be assisted or represented by a person of the 
 enrollee's choice. 

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

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

    Subd. 7.    Standards of review.  (a) For an external 
 review of any issue in an adverse determination that does not 
 require a medical necessity determination, the external review 
 must be based on whether the adverse determination was in 
 compliance with the enrollee's health benefit plan. 

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

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

    Subd. 8.    Effects of external review.  A decision 
 rendered under this section shall be nonbinding on the enrollee 
 and binding on the health plan company.  The health plan company 
 may seek judicial review of the decision on the grounds that the 
 decision was arbitrary and capricious or involved an abuse of 
 discretion. 

    Subd. 9.    Immunity from civil liability.  A person who 
 participates in an external review by investigating, reviewing 
 materials, providing technical expertise, or rendering a 
 decision shall not be civilly liable for any action that is 
 taken in good faith, that is within the scope of the person's 
 duties, and that does not constitute willful or reckless 
 misconduct. 

    Subd. 10.    Data reporting.  The commissioners shall 
 make available to the public, upon request, summary data on the 
 decisions rendered under this section, including the number of 
 reviews heard and decided and the final outcomes.  Any data 
 released to the public must not individually identify the 
 enrollee initiating the request for external review. 

    HIST: 1999 c 239 s 39 

*   NOTE:  This section, as added by Laws 1999, chapter 239, 
*section 39, is effective April 1, 2000, and applies to contracts 
*issued or renewed on or after that date.  Upon request, the 
*commissioner of health or commerce shall grant an extension of 
*up to three months to any health plan company or utilization 
*review organization that is unable to comply with Laws 1999, 
*chapter 239, sections 1, 3 to 42, and 43, paragraphs (a) and (c) 
*by April 1, 2000, due to circumstances beyond the control of the 
*health plan company or utilization review organization.  Laws 
*1999, chapter 239, section 44.

     62Q.74 Network shadow contracting. 

    Subdivision 1.    Definitions.  (a) For purposes of this 
 section, the terms defined in this subdivision have the meanings 
 given. 

    (b) "Category of coverage" means one of the following types 
 of health-related coverage: 

    (1) health; 

    (2) no-fault automobile medical benefits; or 

    (3) workers' compensation medical benefits. 

    (c) "Health care provider" or "provider" has the meaning 
 given in section 148.01. 

    (d) "Network organization" means a preferred provider 
 organization as defined in section 145.61, subdivision 4c; a 
 managed care organization as defined in section 62Q.01, 
 subdivision 5; or other entity that uses or consists of a 
 network of health care providers; but does not include a 
 nonprofit health service plan corporation operating under 
 chapter 62C or its affiliates. 

    Subd. 2.    Provider consent required.  (a) No network 
 organization shall require a health care provider to participate 
 in a network under a category of coverage that differs from the 
 category or categories of coverage to which the existing 
 contract between the network organization and the provider 
 applies, without the consent of the provider obtained under 
 subdivision 3.  

    (b) This section does not apply to situations in which the 
 network organization wishes the provider to participate in a new 
 or different plan or other arrangement within a category of 
 coverage that is already provided for in an existing contract 
 between the network organization and the provider. 

    (c) Compliance with this section may not be waived in a 
 contract or otherwise. 

    Subd. 3.    Consent procedure.  (a) The network 
 organization, if it wishes to apply an existing contract with a 
 provider to a different category of coverage, shall first notify 
 the provider in writing.  The written notice must include at 
 least the following: 

    (1) the network organization's name, address, and telephone 
 number, and the name of the specific network, if it differs from 
 that of the network organization; 

    (2) a description of the proposed new category of coverage; 

    (3) the names of all payers expected by the network 
 organization to use the network for the new category of 
 coverage; 

    (4) the approximate number of current enrollees of the 
 network organization in that category of coverage within the 
 provider's geographical area; 

    (5) a disclosure of all contract terms of the proposed new 
 category of coverage, including the discount or reduced fees, 
 care guidelines, utilization review criteria, prior 
 authorization process, and dispute resolution process; 

    (6) a form for the provider's convenience in accepting or 
 declining participation in the proposed new category of 
 coverage, provided that the provider need not use that form in 
 responding; and 

    (7) a statement informing the provider of the provisions of 
 paragraph (b). 

    (b) If the provider does not decline participation within 
 30 days after the postmark date of the notice, the provider is 
 deemed to have accepted the proposed new category of coverage. 

    Subd. 4.    Contract termination restricted.  A network 
 organization must not terminate an existing contract with a 
 provider, or fail to honor the contract in good faith, based 
 solely on the provider's decision not to accept a proposed new 
 category of coverage.  The most recent agreed-upon contractual 
 obligations remain in force until the existing contract's 
 renewal or termination date. 

    Subd. 5.    Remedy.  If a network organization violates 
 this section by reimbursing a provider as if the provider had 
 agreed under this section to participate in the network under a 
 category of coverage to which the provider has not agreed, the 
 provider has a cause of action against the network organization 
 to recover two times the difference between the reasonable 
 charges for claims affected by the violation and the amounts 
 actually paid to the provider.  The provider is also entitled to 
 recover costs, disbursements, and reasonable attorney fees. 

    HIST: 1999 c 94 s 1