1.1                          A bill for an act 
  1.2             relating to health; modifying the enrollee complaint 
  1.3             system for health maintenance organizations; 
  1.4             establishing an office of health care consumer 
  1.5             assistance, advocacy, and information; extending the 
  1.6             dates for establishing certain health plan dispute 
  1.7             resolution processes; modifying requirements of 
  1.8             counties for participating in medical assistance and 
  1.9             general assistance medical care; requiring a study; 
  1.10            appropriating money; amending Minnesota Statutes 1997 
  1.11            Supplement, sections 62D.11, subdivision 1; 62Q.105, 
  1.12            subdivision 1; 62Q.30; and 256B.692, subdivision 2; 
  1.13            proposing coding for new law in Minnesota Statutes, 
  1.14            chapter 62J. 
  1.15  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.16     Section 1.  Minnesota Statutes 1997 Supplement, section 
  1.17  62D.11, subdivision 1, is amended to read: 
  1.18     Subdivision 1.  [ENROLLEE COMPLAINT SYSTEM.] Every health 
  1.19  maintenance organization shall establish and maintain a 
  1.20  complaint system, as required under section 62Q.105 to provide 
  1.21  reasonable procedures for the resolution of written complaints 
  1.22  initiated by or on behalf of enrollees concerning the provision 
  1.23  of health care services.  "Provision of health services" 
  1.24  includes, but is not limited to, questions of the scope of 
  1.25  coverage, quality of care, and administrative operations.  The 
  1.26  health maintenance organization must inform enrollees that they 
  1.27  may choose to use alternative dispute resolution arbitration to 
  1.28  appeal a health maintenance organization's internal appeal 
  1.29  decision.  The health maintenance organization must also inform 
  1.30  enrollees that they have the right to use arbitration to appeal 
  2.1   a health maintenance organization's internal appeal decision not 
  2.2   to certify an admission, procedure, service, or extension of 
  2.3   stay under section 62M.06.  If an enrollee chooses to use an 
  2.4   alternative dispute resolution process arbitration, the health 
  2.5   maintenance organization must participate. 
  2.6              OFFICE OF HEALTH CARE CONSUMER ASSISTANCE, 
  2.7                      ADVOCACY, AND INFORMATION 
  2.8      Sec. 2.  [62J.77] [DEFINITIONS.] 
  2.9      Subdivision 1.  [APPLICABILITY.] For purposes of sections 
  2.10  62J.77 to 62J.80, the terms defined in this section have the 
  2.11  meanings given them. 
  2.12     Subd. 2.  [ENROLLEE.] "Enrollee" means a natural person 
  2.13  covered by a health plan company, health insurance, or health 
  2.14  coverage plan and includes an insured, policyholder, subscriber, 
  2.15  contract holder, member, covered person, or certificate holder. 
  2.16     Subd. 3.  [PATIENT.] "Patient" means a former, current, or 
  2.17  prospective patient of a health care provider. 
  2.18     Sec. 3.  [62J.78] [ESTABLISHMENT; ORGANIZATION.] 
  2.19     Subdivision 1.  [GENERAL.] The office of health care 
  2.20  consumer assistance, advocacy, and information is established to 
  2.21  provide assistance, advocacy, and information to all health care 
  2.22  consumers within the state.  The office shall have no regulatory 
  2.23  power or authority and shall not provide legal representation in 
  2.24  a court of law. 
  2.25     Subd. 2.  [EXECUTIVE DIRECTOR.] An executive director shall 
  2.26  be appointed by the governor, in consultation with the consumer 
  2.27  advisory board, for a three-year term and may be removed only 
  2.28  for just cause.  The executive director must be selected without 
  2.29  regard to political affiliation and must be a person who has 
  2.30  knowledge and experience concerning the needs and rights of 
  2.31  health care consumers and must be qualified to analyze questions 
  2.32  of law, administrative functions, and public policy.  No person 
  2.33  may serve as executive director while holding another public 
  2.34  office.  The director shall serve in the unclassified service.  
  2.35     Subd. 3.  [STAFF.] The executive director shall appoint at 
  2.36  least nine consumer advocates to discharge the responsibilities 
  3.1   and duties of the office.  The executive director and full-time 
  3.2   staff shall be included in the Minnesota state retirement 
  3.3   association. 
  3.4      Subd. 4.  [DELEGATION.] The executive director may delegate 
  3.5   to staff any of the authority or duties of the director, except 
  3.6   the duty of formally making recommendations to the legislature.  
  3.7      Subd. 5.  [TRAINING.] The executive director shall ensure 
  3.8   that the consumer advocates are adequately trained. 
  3.9      Subd. 6.  [STATEWIDE ADVOCACY.] The executive director 
  3.10  shall assign a consumer advocate to represent each regional 
  3.11  coordinating board's geographic area. 
  3.12     Subd. 7.  [FINANCIAL INTEREST.] The executive director and 
  3.13  staff must not have any direct personal financial interest in 
  3.14  the health care system, except as an individual consumer of 
  3.15  health care services. 
  3.16     Subd. 8.  [ADMINISTRATION.] The office of the ombudsman for 
  3.17  mental health and mental retardation shall coordinate and share 
  3.18  administrative services with the office of health care consumer 
  3.19  assistance, advocacy, and information.  To the extent practical, 
  3.20  all ombudsman offices with health care responsibilities shall 
  3.21  have their telephone systems linked in order to facilitate 
  3.22  immediate referrals. 
  3.23     Sec. 4.  [62J.79] [DUTIES AND POWERS OF THE OFFICE OF 
  3.24  HEALTH CARE CONSUMER ASSISTANCE, ADVOCACY, AND INFORMATION.] 
  3.25     Subdivision 1.  [DUTIES.] The executive director shall 
  3.26  provide information and assistance to all health care consumers 
  3.27  by: 
  3.28     (1) assisting patients and enrollees in understanding and 
  3.29  asserting their contractual and legal rights, including the 
  3.30  rights under an alternative dispute resolution process.  This 
  3.31  assistance may include advocacy for enrollees in administrative 
  3.32  proceedings or other formal or informal dispute resolution 
  3.33  processes; 
  3.34     (2) assisting enrollees in obtaining health care referrals 
  3.35  under their health plan company, health insurance, or health 
  3.36  coverage plan; 
  4.1      (3) assisting patients and enrollees in accessing the 
  4.2   services of governmental agencies, regulatory boards, and other 
  4.3   state consumer assistance programs, ombudsman, or advocacy 
  4.4   services whenever appropriate so that the patient or enrollee 
  4.5   can take full advantage of existing mechanisms for resolving 
  4.6   complaints; 
  4.7      (4) referring patients and enrollees to governmental 
  4.8   agencies and regulatory boards for the investigation of health 
  4.9   care complaints and for enforcement action; 
  4.10     (5) educating and training enrollees about their health 
  4.11  plan company, health insurance, or health coverage plan in order 
  4.12  to enable them to assert their rights and to understand their 
  4.13  responsibilities; 
  4.14     (6) assisting enrollees in receiving a timely resolution of 
  4.15  their complaints; 
  4.16     (7) monitoring health care complaints addressed by the 
  4.17  office to identify specific complaint patterns or areas of 
  4.18  potential improvement; and 
  4.19     (8) recommending to health plan companies ways to identify 
  4.20  and remove any barriers that might delay or impede the health 
  4.21  plan company's effort to resolve consumer complaints.  
  4.22     The executive director shall prioritize the duties listed 
  4.23  in this subdivision within the appropriations allocated.  
  4.24     Subd. 2.  [COMMUNICATION.] The executive director shall 
  4.25  meet at least six times per year with the consumer advisory 
  4.26  board.  The executive director shall share all public 
  4.27  information obtained by the office of health care consumer 
  4.28  assistance, advocacy, and information with the consumer advisory 
  4.29  board in order to assist the consumer advisory board in its role 
  4.30  of advising the commissioners of health and commerce and the 
  4.31  legislature in accordance with section 62J.75. 
  4.32     Subd. 3.  [REPORTS.] Beginning January 15, 1999, the 
  4.33  executive director, on at least a quarterly basis, shall provide 
  4.34  data from the health care complaints addressed by the office to 
  4.35  the commissioners of health and commerce, the consumer advisory 
  4.36  board, the Minnesota council of health plans, the Insurance 
  5.1   Federation of Minnesota, and the information clearinghouse.  
  5.2   Beginning January 15, 1999, the executive director must make an 
  5.3   annual written report to the legislature regarding activities of 
  5.4   the office, including recommendations on improving health care 
  5.5   consumer assistance and complaint resolution processes.  
  5.6      Sec. 5.  [62J.80] [RETALIATION.] 
  5.7      A health plan company or health care provider shall not 
  5.8   retaliate or take adverse action against an enrollee or patient 
  5.9   who, in good faith, makes a complaint against a health plan 
  5.10  company or health care provider.  If retaliation is suspected, 
  5.11  the executive director may report it to the appropriate 
  5.12  regulatory authority.  
  5.13     Sec. 6.  Minnesota Statutes 1997 Supplement, section 
  5.14  62Q.105, subdivision 1, is amended to read: 
  5.15     Subdivision 1.  [ESTABLISHMENT.] Each health plan company 
  5.16  shall establish and make available to enrollees, by July 1, 1998 
  5.17  1999, an informal complaint resolution process that meets the 
  5.18  requirements of this section.  A health plan company must make 
  5.19  reasonable efforts to resolve enrollee complaints, and must 
  5.20  inform complainants in writing of the company's decision within 
  5.21  30 days of receiving the complaint.  The complaint resolution 
  5.22  process must treat the complaint and information related to it 
  5.23  as required under sections 72A.49 to 72A.505.  
  5.24     Sec. 7.  Minnesota Statutes 1997 Supplement, section 
  5.25  62Q.30, is amended to read: 
  5.26     62Q.30 [EXPEDITED FACT FINDING AND DISPUTE RESOLUTION 
  5.27  PROCESS.] 
  5.28     The commissioner shall establish an expedited fact finding 
  5.29  and dispute resolution process to assist enrollees of health 
  5.30  plan companies with contested treatment, coverage, and service 
  5.31  issues to be in effect July 1, 1998 1999.  If the disputed issue 
  5.32  relates to whether a service is appropriate and necessary, the 
  5.33  commissioner shall issue an order only after consulting with 
  5.34  appropriate experts knowledgeable, trained, and practicing in 
  5.35  the area in dispute, reviewing pertinent literature, and 
  5.36  considering the availability of satisfactory alternatives.  The 
  6.1   commissioner shall take steps including but not limited to 
  6.2   fining, suspending, or revoking the license of a health plan 
  6.3   company that is the subject of repeated orders by the 
  6.4   commissioner that suggests a pattern of inappropriate 
  6.5   underutilization.  
  6.6      Sec. 8.  Minnesota Statutes 1997 Supplement, section 
  6.7   256B.692, subdivision 2, is amended to read: 
  6.8      Subd. 2.  [DUTIES OF THE COMMISSIONER OF HEALTH.] 
  6.9   Notwithstanding chapters 62D and 62N, a county that elects to 
  6.10  purchase medical assistance and general assistance medical care 
  6.11  in return for a fixed sum without regard to the frequency or 
  6.12  extent of services furnished to any particular enrollee is not 
  6.13  required to obtain a certificate of authority under chapter 62D 
  6.14  or 62N.  A county that elects to purchase medical assistance and 
  6.15  general assistance medical care services under this section must 
  6.16  satisfy the commissioner of health that the requirements of 
  6.17  chapter 62D, applicable to health maintenance organizations, or 
  6.18  chapter 62N, applicable to community integrated service 
  6.19  networks, will be met.  A county must also assure the 
  6.20  commissioner of health that the requirements of section sections 
  6.21  62J.041; 62J.48; 62J.71 to 62J.73; all applicable provisions of 
  6.22  chapter 62Q, including sections 62Q.07; 62Q.075; 62Q.105; 
  6.23  62Q.1055; 62Q.106; 62Q.11; 62Q.12; 62Q.135; 62Q.14; 62Q.145; 
  6.24  62Q.19; 62Q.23, paragraph (c); 62Q.30; 62Q.43; 62Q.47; 62Q.50; 
  6.25  62Q.52 to 62Q.56; 62Q.58; 62Q.64; and 72A.201 will be met.  All 
  6.26  enforcement and rulemaking powers available under chapters 62D, 
  6.27  62J, and 62N are hereby granted to the commissioner of health 
  6.28  with respect to counties that purchase medical assistance and 
  6.29  general assistance medical care services under this section. 
  6.30     Sec. 9.  [COMPLAINT PROCESS STUDY.] 
  6.31     The complaint process work group established by the 
  6.32  commissioners of health and commerce as required under Laws 
  6.33  1997, chapter 237, section 20, shall continue to meet to develop 
  6.34  a complaint resolution process for health plan companies to make 
  6.35  available to enrollees as required under Minnesota Statutes, 
  6.36  sections 62Q.105, 62Q.11, and 62Q.30.  The commissioners of 
  7.1   health and commerce shall submit a progress report to the 
  7.2   legislative commission on health care access by September 15, 
  7.3   1998, and shall submit final recommendations to the legislature, 
  7.4   including draft legislation on developing such a process by 
  7.5   November 15, 1998.  The recommendations must also include, in 
  7.6   consultation with the work group, a permanent method of 
  7.7   financing the office of health care consumer assistance, 
  7.8   advocacy, and information. 
  7.9      Sec. 10.  [APPROPRIATION.] 
  7.10     $....... is appropriated for fiscal year 1999 from the 
  7.11  general fund to the executive director of the office of health 
  7.12  care consumer assistance, advocacy, and information.