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Minnesota Legislature

Office of the Revisor of Statutes

62D.09 INFORMATION TO ENROLLEES.
    Subdivision 1. Marketing requirements. (a) Any written marketing materials which may be
directed toward potential enrollees and which include a detailed description of benefits provided
by the health maintenance organization shall include a statement of enrollee information and
rights as described in section 62D.07, subdivision 3, paragraphs (b) and (c). Prior to any oral
marketing presentation, the agent marketing the plan must inform the potential enrollees that
any complaints concerning the material presented should be directed to the health maintenance
organization, the commissioner of health, or, if applicable, the employer.
(b) Detailed marketing materials must affirmatively disclose all exclusions and limitations in
the organization's services or kinds of services offered to the contracting party, including but not
limited to the following types of exclusions and limitations:
(1) health care services not provided;
(2) health care services requiring co-payments or deductibles paid by enrollees;
(3) the fact that access to health care services does not guarantee access to a particular
provider type; and
(4) health care services that are or may be provided only by referral of a physician.
(c) No marketing materials may lead consumers to believe that all health care needs will
be covered. All marketing materials must alert consumers to possible uncovered expenses with
the following language in bold print: "THIS HEALTH CARE PLAN MAY NOT COVER
ALL YOUR HEALTH CARE EXPENSES; READ YOUR CONTRACT CAREFULLY TO
DETERMINE WHICH EXPENSES ARE COVERED." Immediately following the disclosure
required under paragraph (b), clause (3), consumers must be given a telephone number to use
to contact the health maintenance organization for specific information about access to provider
types.
(d) The disclosures required in paragraphs (b) and (c) are not required on billboards or
image, and name identification advertisement.
    Subd. 2. Information upon application. The application for coverage by the health
maintenance organization shall be accompanied by the statement of consumer information and
rights as described in section 62D.07, subdivision 3, paragraph (c).
    Subd. 3. Annual report to enrollees. Every health maintenance organization or its
representative shall annually, before June 1, provide to its enrollees the following:
(1) a summary of its most recent annual financial statement including a balance sheet and
statement of receipts and disbursements;
(2) a description of the health maintenance organization, its health care plan or plans, its
facilities and personnel, any material changes therein since the last report;
(3) the current evidence of coverage, or amendments thereto; and
(4) a statement of enrollee information and rights as described in section 62D.07, subdivision
3
, paragraph (c).
Under clause (3), a health maintenance organization may annually alternate between
providing enrollees with amendments and providing current evidence of coverage.
    Subd. 4. Medicare information. Health maintenance organizations which issue contracts
to persons who are covered by title XVIII of the Social Security Act (Medicare) must give the
applicant, at the time of application, an outline containing at least the following information:
(1) a description of the principal benefits and coverage provided in the contract, including
a clear description of nursing home and home care benefits covered by the health maintenance
organization;
(2) a statement of the exceptions, reductions, and limitations contained in the contract;
(3) the following language: "This contract does not cover all skilled nursing home care or
home care services and does not cover custodial or residential nursing care. Read your contract
carefully to determine which nursing home facilities and home care services are covered by your
contract, and what procedures you must follow to receive these benefits.";
(4) a statement of the renewal provisions including any reservation by the health maintenance
organization of the right to change fees;
(5) a statement that the outline of coverage is a summary of the contract issued or applied for
and that the contract should be read to determine governing contractual provisions; and
(6) a statement explaining that the enrollee's Medicare coverage is altered by enrollment with
the health maintenance organization, if applicable.
    Subd. 5. Participating providers. Health maintenance organizations shall provide enrollees
with a list of the names and locations of participating providers to whom enrollees have direct
access without referral no later than the effective date of enrollment or date the evidence of
coverage is issued and upon request. Health maintenance organizations need not provide the
names of their employed providers.
    Subd. 6. List of providers; requirements. Any list of providers issued by the health
maintenance organization shall include the date the list was published and contain a bold type
notice in a prominent location on the list of providers with the following language, or substantially
similar language approved in advance by the commissioner:
"Enrolling in (name of health maintenance organization) does not guarantee services by a
particular provider on this list. If you wish to be certain of receiving care from a specific provider
listed, you should contact that provider to ask whether or not the provider is still a (name of health
maintenance organization) provider and whether or not the provider is accepting additional
patients."
    Subd. 7. Requests for information. Every health maintenance organization shall provide
the information described in section 62D.07, subdivision 3, paragraphs (b) and (c), to enrollees or
their representatives on request, within a reasonable time. Information on how to obtain referrals,
prior authorization, or second opinion shall be given to the enrollee or an enrollee's representative
in person or by telephone within one business day following the day the health maintenance
organization or its representative receives the request for information.
    Subd. 8. Membership cards; summary of complaints. Each health maintenance
organization shall issue a membership card to its enrollees. The membership card must:
(1) identify the health maintenance organization;
(2) include the name, address, and telephone number to call if the enrollee has a complaint;
(3) include the telephone number to call or the instruction on how to receive authorization
for emergency care; and
(4) include one of the following:
(i) the telephone number to call to appeal to or file a complaint with the commissioner of
health; or
(ii) for persons enrolled under section 256B.69, 256B.77, 256D.03, or 256L.12, the telephone
number to call to file a complaint with the ombudsperson designated by the commissioner of
human services under section 256B.69 or the Office of the Ombudsman for Mental Health and
Developmental Disabilities under section 256B.77 and the address to appeal to the commissioner
of human services. The ombudsperson shall annually provide the commissioner of health with
a summary of complaints and actions taken.
History: 1973 c 670 s 9; 1984 c 464 s 24; 1985 c 248 s 25; 1986 c 444; 1988 c 434 s 6;
1988 c 592 s 3-5; 1997 c 205 s 8-10; 1997 c 225 art 2 s 7; 2000 c 474 s 1; 2005 c 56 s 1