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; modifying patient 
  1.10            protection provisions; requiring a study; 
  1.11            appropriating money; amending Minnesota Statutes 1997 
  1.12            Supplement, sections 62D.11, subdivision 1; 62J.70, 
  1.13            subdivision 3; 62J.71, subdivisions 1, 3, and 4; 
  1.14            62J.72, subdivision 1; 62Q.105, subdivision 1; 62Q.30; 
  1.15            and 256B.692, subdivision 2; proposing coding for new 
  1.16            law in Minnesota Statutes, chapters 62J; and 62Q. 
  1.17  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.18                             ARTICLE 1
  1.19                        ENROLLEE ASSISTANCE
  1.20     Section 1.  Minnesota Statutes 1997 Supplement, section 
  1.21  62D.11, subdivision 1, is amended to read: 
  1.22     Subdivision 1.  [ENROLLEE COMPLAINT SYSTEM.] Every health 
  1.23  maintenance organization shall establish and maintain a 
  1.24  complaint system, as required under section 62Q.105 to provide 
  1.25  reasonable procedures for the resolution of written complaints 
  1.26  initiated by or on behalf of enrollees concerning the provision 
  1.27  of health care services.  "Provision of health services" 
  1.28  includes, but is not limited to, questions of the scope of 
  1.29  coverage, quality of care, and administrative operations.  The 
  1.30  health maintenance organization must inform enrollees that they 
  1.31  may choose to use ~~alternative dispute resolution~~ arbitration to 
  2.1   appeal a health maintenance organization's internal appeal 
  2.2   decision.  The health maintenance organization must also inform 
  2.3   enrollees that they have the right to use arbitration to appeal 
  2.4   a health maintenance organization's internal appeal decision not 
  2.5   to certify an admission, procedure, service, or extension of 
  2.6   stay under section 62M.06.  If an enrollee chooses to use ~~an~~ 
  2.7   ~~alternative dispute resolution process~~ arbitration, the health 
  2.8   maintenance organization must participate. 
  2.9              OFFICE OF HEALTH CARE CONSUMER ASSISTANCE, 
  2.10                     ADVOCACY, AND INFORMATION 
  2.11     Sec. 2.  [62J.77] [DEFINITIONS.] 
  2.12     Subdivision 1.  [APPLICABILITY.] For purposes of sections 
  2.13  62J.77 to 62J.80, the terms defined in this section have the 
  2.14  meanings given them. 
  2.15     Subd. 2.  [ENROLLEE.] "Enrollee" means a natural person 
  2.16  covered by a health plan company, health insurance, or health 
  2.17  coverage plan and includes an insured, policyholder, subscriber, 
  2.18  contract holder, member, covered person, or certificate holder. 
  2.19     Subd. 3.  [PATIENT.] "Patient" means a former, current, or 
  2.20  prospective patient of a health care provider. 
  2.21     Sec. 3.  [62J.78] [ESTABLISHMENT; ORGANIZATION.] 
  2.22     Subdivision 1.  [GENERAL.] The office of health care 
  2.23  consumer assistance, advocacy, and information is established to 
  2.24  provide assistance, advocacy, and information to all health care 
  2.25  consumers within the state.  The office shall have no regulatory 
  2.26  power or authority and shall not provide legal representation in 
  2.27  a court of law. 
  2.28     Subd. 2.  [EXECUTIVE DIRECTOR.] An executive director shall 
  2.29  be appointed by the governor, in consultation with the consumer 
  2.30  advisory board, for a three-year term and may be removed only 
  2.31  for just cause.  The executive director must be selected without 
  2.32  regard to political affiliation and must be a person who has 
  2.33  knowledge and experience concerning the needs and rights of 
  2.34  health care consumers and must be qualified to analyze questions 
  2.35  of law, administrative functions, and public policy.  No person 
  2.36  may serve as executive director while holding another public 
  3.1   office.  The director shall serve in the unclassified service.  
  3.2      Subd. 3.  [STAFF.] The executive director shall appoint at 
  3.3   least nine consumer advocates to discharge the responsibilities 
  3.4   and duties of the office.  The executive director and full-time 
  3.5   staff shall be included in the Minnesota state retirement 
  3.6   association. 
  3.7      Subd. 4.  [DELEGATION.] The executive director may delegate 
  3.8   to staff any of the authority or duties of the director, except 
  3.9   the duty of formally making recommendations to the legislature.  
  3.10     Subd. 5.  [TRAINING.] The executive director shall ensure 
  3.11  that the consumer advocates are adequately trained. 
  3.12     Subd. 6.  [STATEWIDE ADVOCACY.] The executive director 
  3.13  shall assign a consumer advocate to represent each regional 
  3.14  coordinating board's geographic area. 
  3.15     Subd. 7.  [FINANCIAL INTEREST.] The executive director and 
  3.16  staff must not have any direct personal financial interest in 
  3.17  the health care system, except as an individual consumer of 
  3.18  health care services. 
  3.19     Subd. 8.  [ADMINISTRATION.] The office of the ombudsman for 
  3.20  mental health and mental retardation shall coordinate and share 
  3.21  administrative services with the office of health care consumer 
  3.22  assistance, advocacy, and information.  To the extent practical, 
  3.23  all ombudsman offices with health care responsibilities shall 
  3.24  have their telephone systems linked in order to facilitate 
  3.25  immediate referrals. 
  3.26     Sec. 4.  [62J.79] [DUTIES AND POWERS OF THE OFFICE OF 
  3.27  HEALTH CARE CONSUMER ASSISTANCE, ADVOCACY, AND INFORMATION.] 
  3.28     Subdivision 1.  [DUTIES.] (a) The executive director shall 
  3.29  provide information and assistance to all health care consumers 
  3.30  by: 
  3.31     (1) assisting patients and enrollees in understanding and 
  3.32  asserting their contractual and legal rights, including the 
  3.33  rights under an alternative dispute resolution process.  This 
  3.34  assistance may include advocacy for enrollees in administrative 
  3.35  proceedings or other formal or informal dispute resolution 
  3.36  processes; 
  4.1      (2) assisting enrollees in obtaining health care referrals 
  4.2   under their health plan company, health insurance, or health 
  4.3   coverage plan; 
  4.4      (3) assisting patients and enrollees in accessing the 
  4.5   services of governmental agencies, regulatory boards, and other 
  4.6   state consumer assistance programs, ombudsman, or advocacy 
  4.7   services whenever appropriate so that the patient or enrollee 
  4.8   can take full advantage of existing mechanisms for resolving 
  4.9   complaints; 
  4.10     (4) referring patients and enrollees to governmental 
  4.11  agencies and regulatory boards for the investigation of health 
  4.12  care complaints and for enforcement action; 
  4.13     (5) educating and training enrollees about their health 
  4.14  plan company, health insurance, or health coverage plan in order 
  4.15  to enable them to assert their rights and to understand their 
  4.16  responsibilities; 
  4.17     (6) assisting enrollees in receiving a timely resolution of 
  4.18  their complaints; 
  4.19     (7) monitoring health care complaints addressed by the 
  4.20  office to identify specific complaint patterns or areas of 
  4.21  potential improvement; 
  4.22     (8) recommending to health plan companies ways to identify 
  4.23  and remove any barriers that might delay or impede the health 
  4.24  plan company's effort to resolve consumer complaints; and 
  4.25     (9) in performing the duties specified in clauses (1) to 
  4.26  (8), taking into consideration the special situations of 
  4.27  patients and enrollees who have unique culturally defined needs.
  4.28     (b) The executive director shall prioritize the duties 
  4.29  listed in this subdivision within the appropriations allocated.  
  4.30     Subd. 2.  [COMMUNICATION.] The executive director shall 
  4.31  meet at least six times per year with the consumer advisory 
  4.32  board.  The executive director shall share all public 
  4.33  information obtained by the office of health care consumer 
  4.34  assistance, advocacy, and information with the consumer advisory 
  4.35  board in order to assist the consumer advisory board in its role 
  4.36  of advising the commissioners of health and commerce and the 
  5.1   legislature in accordance with section 62J.75. 
  5.2      Subd. 3.  [REPORTS.] Beginning January 15, 1999, the 
  5.3   executive director, on at least a quarterly basis, shall provide 
  5.4   data from the health care complaints addressed by the office to 
  5.5   the commissioners of health and commerce, the consumer advisory 
  5.6   board, the Minnesota council of health plans, the Insurance 
  5.7   Federation of Minnesota, and the information clearinghouse.  
  5.8   Beginning January 15, 1999, the executive director must make an 
  5.9   annual written report to the legislature regarding activities of 
  5.10  the office, including recommendations on improving health care 
  5.11  consumer assistance and complaint resolution processes.  
  5.12     Sec. 5.  [62J.80] [RETALIATION.] 
  5.13     A health plan company or health care provider shall not 
  5.14  retaliate or take adverse action against an enrollee or patient 
  5.15  who, in good faith, makes a complaint against a health plan 
  5.16  company or health care provider.  If retaliation is suspected, 
  5.17  the executive director may report it to the appropriate 
  5.18  regulatory authority.  
  5.19     Sec. 6.  Minnesota Statutes 1997 Supplement, section 
  5.20  62Q.105, subdivision 1, is amended to read: 
  5.21     Subdivision 1.  [ESTABLISHMENT.] Each health plan company 
  5.22  shall establish and make available to enrollees, by July 1, ~~1998~~ 
  5.23  1999, an informal complaint resolution process that meets the 
  5.24  requirements of this section.  A health plan company must make 
  5.25  reasonable efforts to resolve enrollee complaints, and must 
  5.26  inform complainants in writing of the company's decision within 
  5.27  30 days of receiving the complaint.  The complaint resolution 
  5.28  process must treat the complaint and information related to it 
  5.29  as required under sections 72A.49 to 72A.505.  
  5.30     Sec. 7.  Minnesota Statutes 1997 Supplement, section 
  5.31  62Q.30, is amended to read: 
  5.32     62Q.30 [EXPEDITED FACT FINDING AND DISPUTE RESOLUTION 
  5.33  PROCESS.] 
  5.34     The commissioner shall establish an expedited fact finding 
  5.35  and dispute resolution process to assist enrollees of health 
  5.36  plan companies with contested treatment, coverage, and service 
  6.1   issues to be in effect July 1, ~~1998~~ 1999.  If the disputed issue 
  6.2   relates to whether a service is appropriate and necessary, the 
  6.3   commissioner shall issue an order only after consulting with 
  6.4   appropriate experts knowledgeable, trained, and practicing in 
  6.5   the area in dispute, reviewing pertinent literature, and 
  6.6   considering the availability of satisfactory alternatives.  The 
  6.7   commissioner shall take steps including but not limited to 
  6.8   fining, suspending, or revoking the license of a health plan 
  6.9   company that is the subject of repeated orders by the 
  6.10  commissioner that suggests a pattern of inappropriate 
  6.11  underutilization.  
  6.12     Sec. 8.  Minnesota Statutes 1997 Supplement, section 
  6.13  256B.692, subdivision 2, is amended to read: 
  6.14     Subd. 2.  [DUTIES OF THE COMMISSIONER OF HEALTH.] 
  6.15  Notwithstanding chapters 62D and 62N, a county that elects to 
  6.16  purchase medical assistance and general assistance medical care 
  6.17  in return for a fixed sum without regard to the frequency or 
  6.18  extent of services furnished to any particular enrollee is not 
  6.19  required to obtain a certificate of authority under chapter 62D 
  6.20  or 62N.  A county that elects to purchase medical assistance and 
  6.21  general assistance medical care services under this section must 
  6.22  satisfy the commissioner of health that the requirements of 
  6.23  chapter 62D, applicable to health maintenance organizations, or 
  6.24  chapter 62N, applicable to community integrated service 
  6.25  networks, will be met.  A county must also assure the 
  6.26  commissioner of health that the requirements of ~~section~~ sections 
  6.27  62J.041; 62J.48; 62J.71 to 62J.73; all applicable provisions of 
  6.28  chapter 62Q, including sections 62Q.07; 62Q.075; 62Q.105; 
  6.29  62Q.1055; 62Q.106; 62Q.11; 62Q.12; 62Q.135; 62Q.14; 62Q.145; 
  6.30  62Q.19; 62Q.23, paragraph (c); 62Q.30; 62Q.43; 62Q.47; 62Q.50; 
  6.31  62Q.52 to 62Q.56; 62Q.58; 62Q.64; and 72A.201 will be met.  All 
  6.32  enforcement and rulemaking powers available under chapters 62D, 
  6.33  62J, and 62N are hereby granted to the commissioner of health 
  6.34  with respect to counties that purchase medical assistance and 
  6.35  general assistance medical care services under this section. 
  6.36     Sec. 9.  [COMPLAINT PROCESS STUDY.] 
  7.1      The complaint process work group established by the 
  7.2   commissioners of health and commerce as required under Laws 
  7.3   1997, chapter 237, section 20, shall continue to meet to develop 
  7.4   a complaint resolution process for health plan companies to make 
  7.5   available to enrollees as required under Minnesota Statutes, 
  7.6   sections 62Q.105, 62Q.11, and 62Q.30.  The commissioners of 
  7.7   health and commerce shall submit a progress report to the 
  7.8   legislative commission on health care access by September 15, 
  7.9   1998, and shall submit final recommendations to the legislature, 
  7.10  including draft legislation on developing such a process by 
  7.11  November 15, 1998.  The recommendations must also include, in 
  7.12  consultation with the work group, a permanent method of 
  7.13  financing the office of health care consumer assistance, 
  7.14  advocacy, and information. 
  7.15     Sec. 10.  [APPROPRIATION.] 
  7.16     $....... is appropriated for fiscal year 1999 from the 
  7.17  general fund to the executive director of the office of health 
  7.18  care consumer assistance, advocacy, and information. 
  7.19                             ARTICLE 2 
  7.20                PATIENT PROTECTION ACT ENHANCEMENTS 
  7.21     Section 1.  Minnesota Statutes 1997 Supplement, section 
  7.22  62J.70, subdivision 3, is amended to read: 
  7.23     Subd. 3.  [HEALTH PLAN COMPANY.] "Health plan company" 
  7.24  means a health plan company as defined in section 62Q.01, 
  7.25  subdivision 4, the medical assistance program, the MinnesotaCare 
  7.26  program, the general assistance medical care program, the state 
  7.27  employee group insurance program, the public employees insurance 
  7.28  program under section 43A.316, and coverage provided by 
  7.29  political subdivisions under section 471.617. 
  7.30     Sec. 2.  Minnesota Statutes 1997 Supplement, section 
  7.31  62J.71, subdivision 1, is amended to read: 
  7.32     Subdivision 1.  [PROHIBITED AGREEMENTS AND DIRECTIVES.] The 
  7.33  following types of agreements and directives are contrary to 
  7.34  state public policy, are prohibited under this section, and are 
  7.35  null and void: 
  7.36     (1) any agreement or directive that prohibits a health care 
  8.1   provider from communicating with an enrollee with respect to the 
  8.2   enrollee's health status, health care, or treatment options, if 
  8.3   the health care provider is acting in good faith and within the 
  8.4   provider's scope of practice as defined by law; 
  8.5      (2) any agreement or directive that prohibits a health care 
  8.6   provider from making a recommendation regarding the suitability 
  8.7   or desirability of a health plan company, health insurer, or 
  8.8   health coverage plan for an enrollee, unless the provider has a 
  8.9   financial conflict of interest in the enrollee's choice of 
  8.10  health plan company, health insurer, or health coverage plan; 
  8.11     (3) any agreement or directive that prohibits a provider 
  8.12  from providing testimony, supporting or opposing legislation, or 
  8.13  making any other contact with state or federal legislators or 
  8.14  legislative staff or with state and federal executive branch 
  8.15  officers or staff; 
  8.16     (4) any agreement or directive that prohibits a health care 
  8.17  provider from disclosing accurate information about whether 
  8.18  services or treatment will be paid for by a patient's health 
  8.19  plan company or health insurer or health coverage plan; and 
  8.20     (5) any agreement or directive that prohibits a health care 
  8.21  provider from informing an enrollee about the nature of the 
  8.22  reimbursement methodology used by an enrollee's health plan 
  8.23  company, health insurer, or health coverage plan to pay the 
  8.24  provider. 
  8.25     Sec. 3.  Minnesota Statutes 1997 Supplement, section 
  8.26  62J.71, subdivision 3, is amended to read: 
  8.27     Subd. 3.  [RETALIATION PROHIBITED.] No person, health plan 
  8.28  company, or other organization may take retaliatory action 
  8.29  against a health care provider solely on the grounds that the 
  8.30  provider: 
  8.31     (1) refused to enter into an agreement or provide services 
  8.32  or information in a manner that is prohibited under this section 
  8.33  or took any of the actions listed in subdivision 1; 
  8.34     (2) disclosed accurate information about whether a health 
  8.35  care service or treatment is covered by an enrollee's health 
  8.36  plan company, health insurer, or health coverage plan; ~~or~~ 
  9.1      (3) discussed diagnostic, treatment, or referral options 
  9.2   that are not covered or are limited by the enrollee's health 
  9.3   plan company, health insurer, or health coverage plan; 
  9.4      (4) criticized coverage or any other aspect of the 
  9.5   enrollee's health plan company, health insurer, or health 
  9.6   coverage plan; or 
  9.7      (5) expressed personal disagreement with a decision made by 
  9.8   a person, organization, or health care provider regarding 
  9.9   treatment or coverage provided to a patient of the provider, or 
  9.10  assisted or advocated for the patient in seeking reconsideration 
  9.11  of such a decision, provided the health care provider makes it 
  9.12  clear that the provider is acting in a personal capacity and not 
  9.13  as a representative of or on behalf of the entity that made the 
  9.14  decision. 
  9.15     Sec. 4.  Minnesota Statutes 1997 Supplement, section 
  9.16  62J.71, subdivision 4, is amended to read: 
  9.17     Subd. 4.  [EXCLUSION.] (a) Nothing in this section 
  9.18  prohibits ~~a health plan~~ an entity that is subject to this 
  9.19  section from taking action against a provider if the ~~health plan~~ 
  9.20  entity has evidence that the provider's actions are illegal, 
  9.21  constitute medical malpractice, or are contrary to accepted 
  9.22  medical practices. 
  9.23     (b) Nothing in this section prohibits a contract provision 
  9.24  or directive that requires any contracting party to keep 
  9.25  confidential or to not use or disclose the specific amounts paid 
  9.26  to a provider, provider fee schedules, provider salaries, and 
  9.27  other similar provider-specific proprietary information of a 
  9.28  specific ~~health plan or health plan company~~ entity that is 
  9.29  subject to this section.  
  9.30     Sec. 5.  Minnesota Statutes 1997 Supplement, section 
  9.31  62J.72, subdivision 1, is amended to read: 
  9.32     Subdivision 1.  [WRITTEN DISCLOSURE.] (a) A health plan 
  9.33  company, as defined under section 62J.70, subdivision 3, a 
  9.34  health care network cooperative as defined under section 62R.04, 
  9.35  subdivision 3, and a health care provider as defined under 
  9.36  section 62J.70, subdivision 2, shall, during open enrollment, 
 10.1   upon enrollment, and annually thereafter, provide enrollees with 
 10.2   a description of the general nature of the reimbursement 
 10.3   methodologies used by the health plan company, health insurer, 
 10.4   or health coverage plan to pay providers.  The description must 
 10.5   explain clearly any aspect of the reimbursement methodology that 
 10.6   in any way may tend to make it advantageous for the health care 
 10.7   provider to minimize or restrict the health care provided to 
 10.8   enrollees.  This description may be incorporated into the member 
 10.9   handbook, subscriber contract, certificate of coverage, or other 
 10.10  written enrollee communication.  The general reimbursement 
 10.11  methodology shall be made available to employers at the time of 
 10.12  open enrollment.  
 10.13     (b) Health plan companies, health care network 
 10.14  cooperatives, and providers must, upon request, provide an 
 10.15  enrollee with specific information regarding the reimbursement 
 10.16  methodology used by that health plan company or health care 
 10.17  network cooperative to reimburse a specific provider, including, 
 10.18  but not limited to, the following information:  
 10.19     (1) a concise written description of the provider payment 
 10.20  plan, including any incentive plan applicable to the enrollee; 
 10.21     (2) a written description of any incentive to the provider 
 10.22  relating to the provision of health care services to enrollees, 
 10.23  including any compensation arrangement that is dependent on the 
 10.24  amount of health coverage or health care services provided to 
 10.25  the enrollee, or the number of referrals to or utilization of 
 10.26  specialists; and 
 10.27     (3) a written description of any incentive plan that 
 10.28  involves the transfer of financial risk to the health care 
 10.29  provider. 
 10.30     (c) The disclosure statement describing the general nature 
 10.31  of the reimbursement methodologies must comply with the 
 10.32  Readability of Insurance Policies Act in chapter 72C~~.~~  
 10.33  ~~Notwithstanding any other law to the contrary, the disclosure~~ 
 10.34  ~~statement may voluntarily be filed with the commissioner for~~ 
 10.35  ~~approval~~ and must be filed with and approved by the commissioner 
 10.36  prior to its use. 
 11.1      (d) A disclosure statement that has ~~voluntarily~~ been filed 
 11.2   with the commissioner for approval under ~~chapter 72C or~~ 
 11.3   ~~voluntarily filed with the commissioner for approval for~~ 
 11.4   ~~purposes other than pursuant to chapter 72C~~ paragraph (c) is 
 11.5   deemed approved 30 days after the date of filing, unless 
 11.6   approved or disapproved by the commissioner on or before the end 
 11.7   of that 30-day period. 
 11.8      (e) The disclosure statement describing the general nature 
 11.9   of the reimbursement methodologies must be provided upon request 
 11.10  in English, Spanish, Vietnamese, and Hmong.  In addition, 
 11.11  reasonable efforts must be made to provide information contained 
 11.12  in the disclosure statement to other non-English-speaking 
 11.13  enrollees. 
 11.14     (f) Health plan companies and providers may enter into 
 11.15  agreements to determine how to respond to enrollee requests 
 11.16  received by either the provider or the health plan company.  
 11.17  This subdivision does not require disclosure of specific amounts 
 11.18  paid to a provider, provider fee schedules, provider salaries, 
 11.19  or other proprietary information of a specific health plan 
 11.20  company or health insurer or health coverage plan or provider. 
 11.21     Sec. 6.  [62Q.107] [PROHIBITED PROVISION; EFFECT OF DENIAL 
 11.22  OF CLAIM.] 
 11.23     No health plan, including the coverages described in 
 11.24  section 62A.011, subdivision 3, clauses (7) and (10), may 
 11.25  contain a provision limiting the standard of review upon which a 
 11.26  court may review denial of a claim or of any other decision made 
 11.27  by a health plan company with respect to an enrollee.  This 
 11.28  section prohibits limiting court review to a determination of 
 11.29  whether the health plan company's decision is arbitrary and 
 11.30  capricious, an abuse of discretion, or any other standard less 
 11.31  favorable to the enrollee than a preponderance of the evidence.  
 11.32     Sec. 7.  [EFFECTIVE DATE.] 
 11.33     Sections 1 to 6 are effective January 1, 1999, and apply to 
 11.34  coverage issued, renewed, or continued as defined in section 
 11.35  60A.02, subdivision 2a, on or after that date.