1999 Minnesota Statutes

     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