1999 Minnesota Statutes

     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.