1998 Minnesota Statutes

     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