1.1                          A bill for an act 
  1.2             relating to insurance; creating a statewide health 
  1.3             care consumer assistance program; prohibiting 
  1.4             contracts that restrict communication between 
  1.5             providers and their patients; requiring certain 
  1.6             disclosures by health care providers and health plan 
  1.7             companies; requiring health plan companies to provide 
  1.8             continuity of care and access to specialty care for 
  1.9             certain enrollees; prohibiting certain exclusive 
  1.10            arrangements; requiring annual certification of 
  1.11            compliance with this act by health plan companies; 
  1.12            appropriating money; amending Minnesota Statutes 1996, 
  1.13            section 181.932, subdivision 1; proposing coding for 
  1.14            new law in Minnesota Statutes, chapters 62J; and 62Q; 
  1.15            repealing Minnesota Statutes 1996, sections 62J.2911; 
  1.16            62J.2912; 62J.2913; 62J.2914; 62J.2915; 62J.2916; 
  1.17            62J.2917; 62J.2918; 62J.2919; 62J.2920; 62J.2921; 
  1.18            62Q.105, subdivisions 2, 3, 4, and 8; and 62Q.11.  
  1.19  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.20     Section 1.  [LEGISLATIVE INTENT.] 
  1.21     It is the intent of the legislature in this Patient 
  1.22  Protection Act to establish additional state consumer 
  1.23  protections and assistance relating to the coverage for and 
  1.24  delivery of health care treatment and services that will 
  1.25  supplement and complement existing laws and regulations and 
  1.26  further ensure that no patient receiving services or treatment 
  1.27  within Minnesota will be harmed by inappropriate health care 
  1.28  practices or treatment, and to provide improved assistance to 
  1.29  consumers and patients who have questions or problems relating 
  1.30  to their health care coverage or treatment. 
  1.31     Sec. 2.  [62J.70] [DEFINITIONS.] 
  1.32     Subdivision 1.  [APPLICABILITY.] For purposes of sections 
  2.1   62J.70 to 62J.72, the terms defined in this subdivision have the 
  2.2   meanings given them. 
  2.3      Subd. 2.  [HEALTH CARE PROVIDER OR PROVIDER.] "Health care 
  2.4   provider" or "provider" means: 
  2.5      (1) a physician, nurse, or other provider as defined under 
  2.6   section 62J.03; 
  2.7      (2) a hospital as defined under section 144.696, 
  2.8   subdivision 3; 
  2.9      (3) an individual or entity that provides health care 
  2.10  coverage or services under the medical assistance, general 
  2.11  assistance medical care, MinnesotaCare, or state employee group 
  2.12  insurance program; and 
  2.13     (4) an association, partnership, corporation, limited 
  2.14  liability corporation, or other organization of persons or 
  2.15  entities described in clause (1) or (2) organized for the 
  2.16  purposes of providing, arranging, or administering health care 
  2.17  services or treatment.  
  2.18     Subd. 3.  [PATIENT.] "Patient" includes a former, current, 
  2.19  or prospective patient of a health care provider.  
  2.20     Subd. 4.  [HEALTH PLAN COMPANY.] "Health plan company" 
  2.21  includes:  any association, partnership, corporation, joint 
  2.22  venture, cooperative, limited liability corporation, or other 
  2.23  organization of persons or entities, including counties, 
  2.24  described in subdivision 2, clauses (1) and (2), organized for 
  2.25  the purposes of providing, arranging, or administering health 
  2.26  care services or treatment.  It includes, but is not limited to, 
  2.27  a third-party administrator of a benefits plan that pays 
  2.28  hospital and medical expense benefits for covered services and 
  2.29  is delivered or issued for delivery in this state by or through 
  2.30  a carrier or any other entity and a managed care plan that 
  2.31  integrates the financing and delivery of appropriate health care 
  2.32  services to covered individuals. 
  2.33     Subd. 5.  [MEDICALLY URGENT COMPLAINT.] "Medically urgent 
  2.34  complaint" involves medically necessary care which is needed as 
  2.35  soon as possible, usually within 24 hours, to protect the health 
  2.36  of the patient.  Medically urgent complaints include, but are 
  3.1   not limited to, medical care that meets the definition of 
  3.2   emergency medical condition set forth in section 62Q.55.  
  3.3      Subd. 6.  [ENROLLEE.] "Enrollee" means an individual 
  3.4   enrolled with a health plan company with regard to coverage. 
  3.5      Subd. 7.  [SUBSTANTIAL FINANCIAL RISK.] Substantial 
  3.6   financial risk is transferred when a plan places a physician, 
  3.7   physician group, or health care provider at risk for more than 
  3.8   25 percent of potential payments.  "Potential payments" means 
  3.9   the maximum anticipated total payments that could be received if 
  3.10  use or costs of referral services were low enough.  "Payments" 
  3.11  include amounts paid to a physician or physician group for 
  3.12  services and administration, and amounts based on use and costs 
  3.13  of referral services.  Potential payments do not include bonuses 
  3.14  and other compensation that are not based on referral levels, 
  3.15  such as bonuses based solely on quality of care, patient 
  3.16  satisfaction, and participation on committees.  
  3.17     Subd. 8.  [NONAPPLICABILITY.] Sections 62J.70 to 62J.72 do 
  3.18  not apply to a trade association, membership association of 
  3.19  health care professionals, or other organization that does not 
  3.20  directly provide, arrange, or administer health care services or 
  3.21  treatment.  
  3.22     Sec. 3.  [62J.71] [PROHIBITED PROVIDER CONTRACTS.] 
  3.23     Subdivision 1.  [AGREEMENTS AND DIRECTIVES PROHIBITED.] The 
  3.24  following types of agreements or directives are contrary to 
  3.25  state public policy, are prohibited under this section, and are 
  3.26  null and void: 
  3.27     (1) any oral or written agreement or directive that 
  3.28  prohibits a health care provider from communicating with a 
  3.29  patient with respect to the patient's health status, health 
  3.30  care, or treatment options, if the health care provider is 
  3.31  acting in good faith and within the provider's scope of practice 
  3.32  as defined by law; 
  3.33     (2) any oral or written agreement or directive that 
  3.34  prohibits a health care provider from disclosing accurate 
  3.35  information about whether services or treatment will be paid for 
  3.36  by a patient's health insurance, health coverage plan, or other 
  4.1   third-party payment arrangement; and 
  4.2      (3) any oral or written agreement or directive that 
  4.3   prohibits a health care provider from informing a patient about 
  4.4   the nature of the reimbursement methodology used by a health 
  4.5   plan company to pay the provider, including any incentives or 
  4.6   penalties intended to encourage providers to withhold services 
  4.7   or minimize or avoid referrals to specialists. 
  4.8      Subd. 2.  [PERSONS AND ENTITIES AFFECTED.] The following 
  4.9   persons and entities shall not enter into any oral or written 
  4.10  agreement, or issue or comply with any directive, that is 
  4.11  prohibited under this section: 
  4.12     (1) a health plan company; 
  4.13     (2) a health care network cooperative as defined under 
  4.14  section 62R.04, subdivision 3; 
  4.15     (3) a health care provider as defined in section 62J.70, 
  4.16  subdivision 2; or 
  4.17     (4) any other individual or entity that delivers, arranges, 
  4.18  or administers health care services or treatment or administers 
  4.19  a health coverage plan.  
  4.20     Subd. 3.  [RETALIATION PROHIBITED.] No person, health plan 
  4.21  company, or other organization may take retaliatory action 
  4.22  against a health care provider solely on the grounds that the 
  4.23  provider: 
  4.24     (1) refused to enter into an agreement or to follow a 
  4.25  directive that is prohibited under this section; 
  4.26     (2) disclosed accurate information about whether a health 
  4.27  care service or treatment is covered by a patient's health 
  4.28  insurance or health coverage plan; 
  4.29     (3) expressed disagreement with a health plan's decision to 
  4.30  deny or limit services to a patient; 
  4.31     (4) assisted a patient in seeking reconsideration of a 
  4.32  health plan decision to deny or limit services; or 
  4.33     (5) offered a personal recommendation to a patient 
  4.34  regarding the selection of a health plan based on the provider's 
  4.35  personal knowledge of the health needs of a patient. 
  4.36     Sec. 4.  [62J.72] [DISCLOSURE OF HEALTH CARE PROVIDER 
  5.1   INFORMATION.] 
  5.2      Subdivision 1.  [INFORMATION ON PATIENTS' MEDICAL BILLS.] A 
  5.3   health plan company and health care provider subject to this act 
  5.4   shall provide patients with a copy of an itemized and 
  5.5   intelligible bill whenever the patient is responsible for paying 
  5.6   any portion of that bill.  The bills must contain descriptive 
  5.7   language sufficient to be understood by the average enrollee. 
  5.8      Subd. 2.  [INFORMATION ON CREDENTIALS OF PROVIDERS.] Any 
  5.9   health care provider who is licensed, credentialed, or 
  5.10  registered by a health-related licensing board as defined under 
  5.11  section 214.01, subdivision 2, must wear a name tag that 
  5.12  indicates by words, letters, abbreviations, or insignia the 
  5.13  profession or occupation of the individual.  The name tag must 
  5.14  be worn whenever the health care provider is rendering health 
  5.15  services to a patient, unless wearing the name tag would create 
  5.16  a safety or health risk to the patient. 
  5.17     Subd. 3.  [INFORMATION ON SURVEYS.] Each health care 
  5.18  provider shall, upon request, provide a summary of any surveys 
  5.19  or results of external surveys it participated in, including, 
  5.20  but not limited to, patient satisfaction and patient access 
  5.21  surveys. 
  5.22     Subd. 4.  [NONAPPLICABILITY.] Health care providers as 
  5.23  defined in section 62J.70, subdivision 2, clause (1), need not 
  5.24  individually provide information required under this section if 
  5.25  it has been provided by another entity that is subject to this 
  5.26  section. 
  5.27     Sec. 5.  [62J.73] [HEALTH CARE CONSUMER ASSISTANCE 
  5.28  PROGRAM.] 
  5.29     Subdivision 1.  [ESTABLISHMENT.] The commissioners of 
  5.30  health and commerce, in consultation with the commissioners of 
  5.31  human services and employee relations, shall establish a 
  5.32  statewide program to provide assistance to consumers, patients, 
  5.33  or enrollees with complaints or problems relating to their 
  5.34  health care or health coverage plan.  The program shall include 
  5.35  a statewide toll-free telephone number.  
  5.36     Subd. 2.  [SELECTION CRITERIA.] The commissioner of 
  6.1   administration shall contract with an agency, organization, or 
  6.2   consortium of organizations to operate the health care consumer 
  6.3   assistance program.  The commissioner shall not contract with an 
  6.4   agency, organization, or consortium that:  
  6.5      (1) has a direct involvement in the licensing, 
  6.6   certification, or accreditation of a health care facility, 
  6.7   health plan company, or health care provider; 
  6.8      (2) has a direct ownership or financial interest in a 
  6.9   health care facility, health plan company, or in providing, 
  6.10  arranging, or administering health care services or treatment; 
  6.11  or 
  6.12     (3) is employed by or is under contract to provide 
  6.13  management services to a health care facility, health plan 
  6.14  company, or an entity that provides, arranges, or administers 
  6.15  health care services or treatment.  
  6.16     Subd. 3.  [FUNCTIONS.] The health care consumer assistance 
  6.17  program shall provide assistance to all health care consumers: 
  6.18     (1) by educating and training consumers about their health 
  6.19  care program or health coverage plan; 
  6.20     (2) in obtaining appropriate referrals and information to 
  6.21  enable consumers to assert their rights as patients; 
  6.22     (3) in obtaining information and outcomes data on health 
  6.23  plan company and health care provider performances; 
  6.24     (4) by identifying and monitoring trends in patient 
  6.25  complaints about health care coverage and services; 
  6.26     (5) by providing patients referrals to another state 
  6.27  consumer assistance, ombudsman, or advocacy service whenever 
  6.28  possible; and 
  6.29     (6) by assisting patients in understanding their 
  6.30  contractual and legal rights, including the rights under the 
  6.31  dispute resolution process.  This assistance can include 
  6.32  advocacy for patients in administration proceedings or other 
  6.33  formal dispute resolution processes, where appropriate.  
  6.34     Subd. 4.  [CONSUMER ADVISORY BOARD.] (a) The consumer 
  6.35  advisory board consists of 18 members appointed in accordance 
  6.36  with paragraph (b).  All members must be public, consumer 
  7.1   members who: 
  7.2      (1) do not have and never have had a material interest in 
  7.3   either the provision of health care services or in an activity 
  7.4   directly related to the provision of health care services, such 
  7.5   as health insurance sales or health plan administration; and 
  7.6      (2) are not registered lobbyists. 
  7.7      (b) The governor, the speaker of the house of 
  7.8   representatives, and the subcommittee on committees of the 
  7.9   committee on rules and administration of the senate shall each 
  7.10  appoint two members.  The Indian affairs council, the council on 
  7.11  affairs of Chicano/Latino people, the council on Black 
  7.12  Minnesotans, the council on Asian-Pacific Minnesotans, 
  7.13  Mid-Minnesota Legal Assistance, and the Minnesota chamber of 
  7.14  commerce shall each appoint one member.  The member appointed by 
  7.15  the Minnesota chamber of commerce must represent small business 
  7.16  interests.  The health care campaign of Minnesota, Minnesotans 
  7.17  for affordable health care, and consortium for citizens with 
  7.18  disabilities shall each appoint two members.  Members serve 
  7.19  without compensation or reimbursement for expenses. 
  7.20     (c) The board shall: 
  7.21     (1) advise the commissioner in preparing a request for 
  7.22  proposals for the contract required by subdivision 2; 
  7.23     (2) make recommendations to the commissioner and the 
  7.24  operator of the health care consumer assistance program during 
  7.25  its implementation and operation, including recommendations on 
  7.26  future funding levels and mechanisms; and 
  7.27     (3) report to the legislature by January 15 of each year on 
  7.28  the level of consumer protections contained in self-insured 
  7.29  plans and on trends in patient complaints and resolution of 
  7.30  those complaints.  The board and this subdivision expire June 
  7.31  30, 2001. 
  7.32     Subd. 5.  [IMMUNITY.] Employees, or persons employed by an 
  7.33  entity contracting with, the health care consumer assistance 
  7.34  program are immune from liability to the same extent as an 
  7.35  ombudsman under section 245.96. 
  7.36     Sec. 6.  [62J.74] [CERTIFICATE OF COMPLIANCE.] 
  8.1      Subdivision 1.  [SCOPE OF APPLICATION.] No department or 
  8.2   agency of the state shall accept any bid or proposal for a 
  8.3   contract or agreement or execute any contract or agreement for 
  8.4   provision of health care coverage or services under medical 
  8.5   assistance, general assistance medical care, state employee 
  8.6   benefit plans, or MinnesotaCare program in excess of $50,000, 
  8.7   unless the health plan company has received a certificate of 
  8.8   compliance issued by the commissioner of health.  The 
  8.9   certificate of compliance signifies that the health plan company 
  8.10  has the contracts and arrangements in place in all health plans 
  8.11  and contracts it administers or participates in to comply with 
  8.12  the patient protection act including the requirements in 
  8.13  sections 62J.70 to 62J.72 and 62Q.53 to 62Q.62.  The health plan 
  8.14  company may apply for a certificate of compliance by presenting 
  8.15  an adequate patient protection plan which addresses matters 
  8.16  raised in this act or by submitting the underlying contracts and 
  8.17  disclosures for the commissioner of health to review.  Receipt 
  8.18  of a certificate of compliance issued by the commissioner of 
  8.19  health shall signify that the health plan company has a plan 
  8.20  that has been approved by the commissioner of health.  A 
  8.21  certificate shall be valid for two years. 
  8.22     Subd. 2.  [REVOCATION OF CERTIFICATE.] Certificates of 
  8.23  compliance may be suspended or revoked by the commissioner of 
  8.24  health if the holder of a certificate has not made a good faith 
  8.25  effort to implement provisions of this act. 
  8.26     Subd. 3.  [REVOCATION OF CONTRACT.] A contract awarded by 
  8.27  the department or agency of the state may be terminated or 
  8.28  abridged by the department or agency because of suspension or 
  8.29  revocation of a certificate based upon a contract or failure to 
  8.30  implement or make a good faith effort to implement the 
  8.31  provisions of this patient protection act.  If a contract is 
  8.32  awarded to a person who does not have a contract compliance 
  8.33  certificate required under this subdivision, the commissioner of 
  8.34  health may void the contract on behalf of the state. 
  8.35     Subd. 4.  [RULES.] The commissioner of health shall adopt 
  8.36  rules to implement this section by specifying the criteria used 
  9.1   to review compliance with this act. 
  9.2      Sec. 7.  [62J.75] [SEVERABILITY.] 
  9.3      If any of a section, subdivision, clause, phrase, or work 
  9.4   of this act is for any reason held to be unconstitutional or in 
  9.5   violation of federal law, the decision shall not affect the 
  9.6   validity of the remaining portions of this act.  To the extent 
  9.7   allowed by federal law, this act shall be interpreted and 
  9.8   construed to fulfill the intent of the legislature to establish 
  9.9   universal patient protections and consumer assistance that will 
  9.10  protect and assist any Minnesota patient or consumer without 
  9.11  regard to the nature of the individual's health status or 
  9.12  condition, need for care or treatment, type of health care 
  9.13  provider used, health coverage, or status as a recipient of 
  9.14  public assistance. 
  9.15     Sec. 8.  [62J.76] [ENFORCEMENT.] 
  9.16     Subdivision 1.  [AUTHORITY.] The commissioners of health 
  9.17  and commerce shall each periodically review contracts and 
  9.18  arrangements among health care providing entities and health 
  9.19  plan companies they regulate to determine compliance with 
  9.20  sections 62J.70 to 62J.76.  Any person may submit a contract or 
  9.21  arrangement to the relevant commissioner for review if the 
  9.22  person believes sections 62J.70 to 62J.76 have been violated.  
  9.23  Any provision of a contract or arrangement found by the relevant 
  9.24  commissioner to violate this section is null and void, and the 
  9.25  relevant commissioner may assess civil penalties against the 
  9.26  health plan company in an amount not to exceed $2,500 for each 
  9.27  day the contract or arrangement is in effect, and may use the 
  9.28  enforcement procedures otherwise available to the commissioner. 
  9.29     Subd. 2.  [ASSISTANCE TO LICENSING BOARDS.] A 
  9.30  health-related licensing board as defined under section 214.01, 
  9.31  subdivision 2, may submit a contract or arrangement to the 
  9.32  relevant commissioner for review if the board believes sections 
  9.33  62J.70 to 62J.76 have been violated.  If the commissioner 
  9.34  determines that any provision of a contract or arrangement 
  9.35  violates those sections, the board may take disciplinary action 
  9.36  against any person who is licensed or regulated by the board who 
 10.1   entered into the contract arrangement. 
 10.2      Sec. 9.  [62J.77] [NONPREEMPTION.] 
 10.3      Nothing in this act preempts or replaces requirements 
 10.4   related to patient protections that are more protective of 
 10.5   patient rights than the requirements established in this act. 
 10.6      Sec. 10.  [62Q.53] [COMPLAINT AND APPEAL MECHANISMS.] 
 10.7      Subdivision 1.  [PURPOSE.] A health plan company shall 
 10.8   establish and administer an internal appeal procedure.  Pursuant 
 10.9   to this procedure, an enrollee shall be entitled to seek a 
 10.10  review of any determination by the health plan company that 
 10.11  relates to health care quality, services, treatment, or access 
 10.12  to needed services. 
 10.13     Subd. 2.  [FILING.] A health plan company subject to this 
 10.14  chapter shall provide written notice of its internal appeal 
 10.15  procedure to its enrollees in its certificate of coverage and 
 10.16  open enrollment materials.  The health plan company also shall 
 10.17  provide enrollees with written notice of the appeal procedure 
 10.18  any time access to a referral is ended or denied or a 
 10.19  determination is made that a requested benefit is not covered 
 10.20  under the contract.  The notice shall describe: 
 10.21     (1) the process for filing a complaint and appeal from the 
 10.22  initial resolution of the complaint; 
 10.23     (2) the time frames within which determinations of 
 10.24  complaints and appeals must be made; 
 10.25     (3) the right of the enrollee to file a separate complaint 
 10.26  with the Minnesota department of health or commerce; 
 10.27     (4) the ability of the enrollee to request mediation and 
 10.28  arbitration under section 62Q.54 at any time during the appeal 
 10.29  process; and 
 10.30     (5) the availability of referrals and assistance for health 
 10.31  care consumers through the statewide health care consumer 
 10.32  assistance program. 
 10.33     Subd. 3.  [ACCESSIBILITY.] The health plan company shall 
 10.34  assure that the complaint and appeal procedure is accessible to 
 10.35  those who do not speak English and shall provide a mechanism in 
 10.36  which an oral complaint may be initiated by calling a toll-free 
 11.1   telephone number, which will be available no less than 40 hours 
 11.2   per week during normal business hours and, in the case of 
 11.3   medically urgent appeals, on a 24-hour-a-day, 7-days-a-week 
 11.4   basis. 
 11.5      Subd. 4.  [TIMELINES.] All complaints must be resolved in 
 11.6   an expeditious manner and in any event the health plan company 
 11.7   shall make a determination and provide notice no more than: 
 11.8      (1) 48 hours after receipt of a medically urgent complaint; 
 11.9      (2) 15 days after receipt of the complaint in the case of 
 11.10  requests for referrals to specialists; and 
 11.11     (3) 30 days after receipt of the complaint in all other 
 11.12  instances. 
 11.13     Subd. 5.  [APPEALS FROM INITIAL DENIAL.] Individuals 
 11.14  reviewing the complaints must include health care professionals 
 11.15  who are licensed, trained, and practicing in the area involved 
 11.16  in the complaint.  If a decision by a health plan company 
 11.17  regarding an initial complaint is partially or wholly adverse to 
 11.18  the enrollee, the health plan company shall provide detailed 
 11.19  written reasons for the denial and the information in 
 11.20  subdivision 2.  The person or persons conducting the internal 
 11.21  appeal from a denial of a complaint must have the authority to 
 11.22  resolve the appeal and must not be the person or persons who 
 11.23  decided the enrollee's original complaint.  The determination of 
 11.24  the appeal and notice to the enrollee shall occur no more than: 
 11.25     (1) 48 hours after the appeal is requested when a medically 
 11.26  urgent complaint is involved; 
 11.27     (2) 15 business days after the appeal is requested in the 
 11.28  case of requests for referrals to specialist care; and 
 11.29     (3) 30 days after receipt of the appeal in all other 
 11.30  instances. 
 11.31     If the internal appeal is partially or wholly adverse to 
 11.32  the enrollee, the health plan company shall provide the enrollee 
 11.33  with the basis for the determination and, in the case of 
 11.34  clinical determinations, the credentials of the organization's 
 11.35  personnel who reviewed the appeal, and the information specified 
 11.36  in subdivision 2. 
 12.1      Sec. 11.  [62Q.54] [IMPARTIAL ALTERNATIVE DISPUTE 
 12.2   RESOLUTION.] 
 12.3      Subdivision 1.  [GENERAL.] Mediation and arbitration 
 12.4   services shall be provided by a contractor selected through the 
 12.5   process set out in subdivision 2.  The health plan company shall 
 12.6   participate in alternative dispute resolution pursuant to this 
 12.7   subdivision if the right to mediation and arbitration is invoked 
 12.8   by the enrollee.  Mediation and arbitration services must be 
 12.9   accessible to those who do not speak English.  The nature of 
 12.10  mediation and arbitration, including the nature and impact of 
 12.11  agreeing to binding arbitration, must be made clear by the 
 12.12  contractor to the enrollees and the health plan company.  An 
 12.13  arbitration must be handled on an expedited basis, in any event 
 12.14  no longer than 30 days after receipt of the request for 
 12.15  arbitration, if either a medically urgent complaint is involved 
 12.16  or a delay would significantly increase the risk to the 
 12.17  enrollee's health.  The enrollee may drop a complaint at any 
 12.18  point in this alternative dispute resolution process until and 
 12.19  unless the enrollee initiates binding arbitration.  Only the 
 12.20  enrollee can initiate binding arbitration.  The health plan 
 12.21  company must develop a procedure that allows enrollees with 
 12.22  medically urgent complaints to request a bypass of the internal 
 12.23  complaint process and proceed immediately to arbitration.  A 
 12.24  judgment upon an award rendered by the arbitrator may be entered 
 12.25  in any court having jurisdiction under sections 572.16 and 
 12.26  572.21. 
 12.27     Subd. 2.  [SELECTION PROCESS.] The commissioner of 
 12.28  administration, in consultation with the commissioners of health 
 12.29  and commerce, shall contract with an agency, organization or 
 12.30  consortium of organizations with expertise in the law and in 
 12.31  alternative dispute resolution to operate the alternative 
 12.32  dispute resolution program.  The commissioner shall not contract 
 12.33  with an agency or organization that: 
 12.34     (1) has a direct involvement in the licensing, 
 12.35  certification, or accreditation of a health care facility, 
 12.36  health plan company, or health care provider; 
 13.1      (2) has a direct ownership or financial interest in a 
 13.2   health care facility, health plan company, or in providing, 
 13.3   arranging, or administering health care services or treatment; 
 13.4   or 
 13.5      (3) is employed by or is under contract to provide 
 13.6   management services to a health care facility, health plan 
 13.7   company, or an entity that provides, arranges, or administers 
 13.8   health care services or treatment. 
 13.9      Subd. 3.  [STAY.] Procedures under this alternative dispute 
 13.10  resolution process are stayed when the enrollee files suit 
 13.11  against the health plan company or when the enrollee makes the 
 13.12  health plan company a party to the enrollee's suit against 
 13.13  another party concerning the facts giving rise to the enrollee 
 13.14  complaint.  Upon decision on the merits, the enrollee is deemed 
 13.15  to have waived the remedies under this section.  If an 
 13.16  enrollee's case is dismissed for reasons other than on the 
 13.17  merits or if the enrollee and the health plan company agree, the 
 13.18  enrollee may access the procedures under this section. 
 13.19     Subd. 4.  [COSTS.] Access to the appeals system, mediation, 
 13.20  and arbitration must be at no cost to the enrollee, except that 
 13.21  the health plan company is not responsible for any attorney's 
 13.22  fees incurred by the enrollee.  Mediation and arbitration costs 
 13.23  must be borne by the health plan company. 
 13.24     Sec. 12.  [62Q.55] [EMERGENCY SERVICES.] 
 13.25     (a) Enrollees have the right to available and accessible 
 13.26  services, including emergency services, 24 hours a day and seven 
 13.27  days a week.  The health plan company shall inform its enrollees 
 13.28  how to obtain emergency care and shall make available a 
 13.29  toll-free number, which is answered 24 hours a day, to answer 
 13.30  questions about emergency services and to receive reports and 
 13.31  provide authorizations, where appropriate, for treatment of 
 13.32  emergency medical conditions.  Emergency services shall be 
 13.33  covered whether provided by participating or nonparticipating 
 13.34  providers and whether provided within or outside the health plan 
 13.35  company's service area.  In determining whether care is 
 13.36  reimbursable as an emergency medical condition, the health plan 
 14.1   company shall take the following factors into consideration: 
 14.2      (1) a reasonable layperson's belief that the circumstances 
 14.3   required immediate medical care that could not wait until the 
 14.4   next working day or next available clinic appointment; 
 14.5      (2) the time of day and day of the week the care was 
 14.6   provided; 
 14.7      (3) the presenting symptoms, including, but not limited to, 
 14.8   severe pain, to ensure that the decision to reimburse the 
 14.9   emergency care is not made solely on the basis of the actual 
 14.10  diagnosis; 
 14.11     (4) the enrollee's efforts to follow the health plan 
 14.12  company's established procedures for obtaining emergency care; 
 14.13  and 
 14.14     (5) any circumstances that precluded use of the health plan 
 14.15  company's established procedures for obtaining emergency care. 
 14.16     (b) The health plan company may require enrollees to notify 
 14.17  the health plan company of nonreferred emergency care as soon as 
 14.18  possible, but not less than 48 hours, after the emergency care 
 14.19  is initially provided.  However, emergency care which would have 
 14.20  been provided under the contract had notice been provided within 
 14.21  the set time frame must be covered. 
 14.22     Sec. 13.  [62Q.56] [CONTINUITY OF CARE.] 
 14.23     Subdivision 1.  [CHANGE IN HEALTH PLANS.] (a) A health plan 
 14.24  company must provide coverage for all covered services provided 
 14.25  to a new enrollee by a health care provider who is not a member 
 14.26  of the health plan company's provider network or is not under 
 14.27  contract with the health plan company to provide health services 
 14.28  if at the time of enrollment the enrollee is receiving an 
 14.29  ongoing course of treatment from that health care provider and 
 14.30  meets one of the following conditions: 
 14.31     (1) has a life-threatening physical condition, mental 
 14.32  condition, or chronic health care condition; 
 14.33     (2) has a degenerative disease, physical disability, mental 
 14.34  illness, chronic health care condition, or mental retardation or 
 14.35  other related conditions; 
 14.36     (3) has entered the second trimester of pregnancy prior to 
 15.1   the time of enrollment; 
 15.2      (4) is receiving culturally appropriate services and the 
 15.3   health plan company does not have a provider in its preferred 
 15.4   provider network with special expertise in the delivery of these 
 15.5   culturally appropriate services; or 
 15.6      (5) does not speak English and the health plan company does 
 15.7   not have a provider in its preferred provider network that 
 15.8   speaks the language spoken by the enrollee. 
 15.9      (b) This subdivision applies only to group coverage and 
 15.10  continuation and conversion coverage. 
 15.11     Subd. 2.  [CHANGE IN HEALTH CARE PROVIDER.] If a health 
 15.12  care provider leaves a health plan company provider network or 
 15.13  if a health plan company terminates the contract of a provider 
 15.14  for reasons other than a violation of the provider's license, 
 15.15  the health plan company must continue to provide coverage for 
 15.16  all covered services provided by the health care provider to an 
 15.17  enrollee of the health plan if at the time of termination the 
 15.18  provider is providing services to the enrollee for an ongoing 
 15.19  course of treatment. 
 15.20     Subd. 3.  [LIMITATIONS.] (a) Subdivisions 1 and 2 apply 
 15.21  only if the enrollee's health care provider agrees to: 
 15.22     (1) accept as payment in full the health plan company's 
 15.23  reimbursement rate for out-of-network providers for the same or 
 15.24  similar services; 
 15.25     (2) adhere to the health plan company's preauthorization 
 15.26  requirements; and 
 15.27     (3) provide the health plan company with all necessary 
 15.28  medical information related to the care provided to the enrollee.
 15.29     (b) An enrollee may receive coverage for all covered 
 15.30  services related to an ongoing course of treatment as described 
 15.31  in subdivision 2 for a period of up to 120 days, or through 
 15.32  delivery if the enrollee is pregnant.  This limitation may be 
 15.33  extended by agreement of the health plan company, health care 
 15.34  provider, and the enrollee.  
 15.35     (c) Nothing in this section requires a health plan to 
 15.36  provide coverage for a health care service or treatment that is 
 16.1   not covered under the enrollee's health plan. 
 16.2      Sec. 14.  [62Q.58] [ACCESS TO SPECIALTY CARE.] 
 16.3      Subdivision 1.  [STANDING REFERRAL.] A health plan company 
 16.4   must establish a procedure by which enrollees may apply for and, 
 16.5   if appropriate, receive a standing referral to a health care 
 16.6   provider who is a specialist.  This procedure for a standing 
 16.7   referral must specify the necessary managed care review and 
 16.8   approval an enrollee must obtain before such a standing referral 
 16.9   is permitted. 
 16.10     Subd. 2.  [MANDATORY STANDING REFERRAL.] An enrollee who 
 16.11  requests a standing referral to a specialist must be given a 
 16.12  standing referral to an appropriate specialist if the enrollee 
 16.13  meets any of the following conditions: 
 16.14     (1) has a life-threatening physical condition, mental 
 16.15  condition, or chronic health care condition; 
 16.16     (2) has a degenerative disease, physical disability, mental 
 16.17  illness, chronic health care condition, or mental retardation or 
 16.18  other related conditions; or 
 16.19     (3) has entered the second trimester of pregnancy and the 
 16.20  pregnancy has been assessed by the health plan as high risk.  
 16.21     Subd. 3.  [COORDINATION OF SERVICES.] An enrollee who 
 16.22  receives a standing referral under subdivision 1 or 2 may 
 16.23  request that the health plan company permit the specialist to 
 16.24  become the enrollee's primary care provider and manage all 
 16.25  medical care appropriate to the enrollee, including primary 
 16.26  care, authorization of tests and services, and all other 
 16.27  services covered under the enrollee benefit plan.  Health plan 
 16.28  companies must establish a procedure for approval of a request 
 16.29  for coordination of services through a relevant specialist.  
 16.30     Subd. 4.  [DISCLOSURE.] A clear statement of the procedures 
 16.31  established under subdivisions 1 to 3 must be included as part 
 16.32  of any direct-marketing materials and enrollment packets and 
 16.33  evidence of coverage provided to consumers.  
 16.34     Sec. 15.  [62Q.62] [PROHIBITION ON EXCLUSIVE ARRANGEMENTS.] 
 16.35     Subdivision 1.  [EXCLUSIVE ARRANGEMENT.] For purposes of 
 16.36  this section, "exclusive arrangement" means any agreement or 
 17.1   contract, including but not limited to, acquisition, purchase, 
 17.2   affiliation, or consulting agreements with a health plan company 
 17.3   or health care provider, which has the purpose or effect of:  
 17.4      (1) committing any person providing health care services to 
 17.5   accept and treat as patients the enrollees of a health plan 
 17.6   company to the exclusion of enrollees who have coverage through 
 17.7   any other health plan company; 
 17.8      (2) providing reimbursement on sliding scales, capitation 
 17.9   rates, payment schedules, or other payment arrangements as a 
 17.10  financial incentive for persons providing health care services 
 17.11  to restrict treatment to enrollees who have coverage through any 
 17.12  other health plan company; 
 17.13     (3) providing reimbursement on sliding scales, capitation 
 17.14  rates, payment schedules, or other payment arrangements that 
 17.15  contain a financial penalty for failing to restrict treatment to 
 17.16  enrollees who have coverage through any other health plan 
 17.17  company; 
 17.18     (4) restricting any person's right to provide health 
 17.19  services, goods, or procedures to another provider or health 
 17.20  plan company; or 
 17.21     (5) preventing any person providing goods or health care 
 17.22  services from contracting with any health plan company or 
 17.23  provider. 
 17.24     Subd. 2.  [PROHIBITION.] No provider or health plan company 
 17.25  shall enter into any new exclusive arrangement or renew an 
 17.26  existing exclusive arrangement with any person, unless the 
 17.27  person is an employee.  No provider or health plan company shall 
 17.28  maintain any existing exclusive arrangement or engage in any act 
 17.29  or practice that would result in exclusive arrangements with any 
 17.30  person, unless that person is an employee.  
 17.31     Subd. 3.  [ENFORCEMENT.] (a) The commissioners of health 
 17.32  and commerce shall each periodically review contracts and 
 17.33  arrangements among health care providing entities and health 
 17.34  plan companies they regulate to determine compliance with this 
 17.35  section.  Any person may submit a contract or arrangement to the 
 17.36  relevant commissioner for review if the person believes this 
 18.1   section has been violated.  Any provision of a contract or 
 18.2   arrangement found by the relevant commissioner to violate this 
 18.3   section is null and void, and the relevant commissioner may 
 18.4   assess civil penalties against the health plan company in an 
 18.5   amount not to exceed $2,500 for each day the contract is in 
 18.6   effect and may use the enforcement procedures otherwise 
 18.7   available to the commissioner.  
 18.8      (b) A health-related licensing board as defined under 
 18.9   section 214.01, subdivision 2, may submit a contract or 
 18.10  arrangement to the relevant commissioner for review if the board 
 18.11  believes this section has been violated.  If the commissioner 
 18.12  determines that any provision of a contract or arrangement 
 18.13  violates this section, the board may take disciplinary action 
 18.14  against any person who is licensed or regulated by the board who 
 18.15  entered into the contract or arrangement.  
 18.16     Sec. 16.  [62Q.63] [DISCLOSURE OF CERTAIN FINANCIAL 
 18.17  ARRANGEMENTS.] 
 18.18     Subdivision 1.  [GENERAL REQUIREMENT.] No health plan 
 18.19  company as defined in section 62Q.01, subdivision 4, shall 
 18.20  offer, sell, issue, or renew a health plan, as defined in 
 18.21  section 62Q.01, subdivision 3, to an enrollee or prospective 
 18.22  enrollee without providing to the enrollee or prospective 
 18.23  enrollee a disclosure statement that meets the requirements of 
 18.24  subdivision 2.  The disclosure statement must be provided at 
 18.25  least annually. 
 18.26     Subd. 2.  [CONTENTS AND FORM OF DISCLOSURE.] (a) The 
 18.27  disclosure statement required in subdivision 1 must disclose and 
 18.28  explain clearly to the enrollee or prospective enrollee any 
 18.29  financial arrangements between the health plan company and any 
 18.30  health care provider that in any way make it advantageous for 
 18.31  the health care provider to minimize or restrict the health care 
 18.32  provided to enrollees under the health plan.  Financial 
 18.33  arrangements to which this section applies include, but are not 
 18.34  limited to, capitation, withhold arrangements, utilization 
 18.35  standards used to evaluate health care providers, arrangements 
 18.36  in which health care providers are subject to terms of 
 19.1   compensation or contract renewal in a future time period that 
 19.2   penalize the health care providers for providing care to 
 19.3   enrollees in the current time period, and any other arrangement 
 19.4   that may have the potential to create a conflict between the 
 19.5   best interest of the enrollee and the best interest of the 
 19.6   health care provider.  Financial arrangements with health care 
 19.7   providers who are employed by the health plan company, or by an 
 19.8   affiliate, are subject to this section.  
 19.9      (b) The disclosure statement must comply with the 
 19.10  Readability of Insurance Policies Act in chapter 72C and be 
 19.11  approved by the commissioner prior to its use.  A disclosure 
 19.12  statement that has been filed with the commissioner for approval 
 19.13  is deemed approved 30 days after the date of filing unless 
 19.14  approved or disapproved by the commissioner on or before the end 
 19.15  of that 30-day period. 
 19.16     (c) For purposes of this section: 
 19.17     (1) "capitation" means a financial arrangement in which a 
 19.18  health plan company compensates a health care provider, 
 19.19  partially or entirely, through a fixed payment per time period 
 19.20  per enrollee served by that health care provider, without regard 
 19.21  to the services actually provided to enrollees by that health 
 19.22  care provider.  The services covered by the capitation may 
 19.23  include the health care provider's own services, referral 
 19.24  services, or all health care services; 
 19.25     (2) "financial arrangement" means an agreement between a 
 19.26  health plan company, or an affiliate of it, and a health care 
 19.27  provider, or an affiliate of it, that determines, or provides a 
 19.28  methodology for determining, the payments to be made by the 
 19.29  health plan company to the health care provider for providing 
 19.30  health care to the health plan company's enrollees; 
 19.31     (3) "affiliate" has the meaning given in section 60D.15, 
 19.32  subdivision 2; and 
 19.33     (4) "withhold" means a financial arrangement in which a 
 19.34  health plan company deducts amounts from its payments to a 
 19.35  health care provider, where the deducted amounts or a portion of 
 19.36  them may eventually be paid to the health care provider at the 
 20.1   end of a specified time period, based upon specific 
 20.2   predetermined factors. 
 20.3      Subd. 3.  [EXEMPTION.] A health plan company that does not 
 20.4   use any arrangement described in subdivision 2 in connection 
 20.5   with a health plan may apply to the commissioner for an 
 20.6   exemption from subdivision 1 with respect to that health plan.  
 20.7   If the commissioner grants the exemption, the health plan 
 20.8   company need not provide a disclosure statement with respect to 
 20.9   that health plan. 
 20.10     Subd. 4.  [GROUP HEALTH PLANS.] With respect to group 
 20.11  health plans, the health plan company must comply with 
 20.12  subdivision 1 by providing the disclosure statement to the group 
 20.13  policyholder or prospective group policyholder and by requiring 
 20.14  the group policyholder to provide the disclosure statement to 
 20.15  each enrollee or prospective enrollee prior to initial 
 20.16  enrollment, at each renewal of the group health plan, and at 
 20.17  each open enrollment period.  Any literature prepared by the 
 20.18  health plan company for distribution to prospective enrollees 
 20.19  must contain the disclosure statement or state that it is 
 20.20  available from the health plan company or from the group 
 20.21  policyholder upon request.  The health plan company shall retain 
 20.22  in its files, for purposes of compliance audits, proof that the 
 20.23  health plan company and group policyholder complied with this 
 20.24  subdivision. 
 20.25     Subd. 5.  [FAMILY COVERAGE.] With respect to family 
 20.26  coverage, the disclosure statement required under this section 
 20.27  must be provided to the enrollee to whom the policy, contract, 
 20.28  or certificate is issued or is to be issued and need not be 
 20.29  provided to enrollees or prospective enrollees who are that 
 20.30  person's dependents. 
 20.31     Sec. 17.  [62Q.64] [DISCLOSURE OF EXECUTIVE COMPENSATION.] 
 20.32     (a) Each nonprofit health plan company doing business in 
 20.33  this state shall annually file with the consumer advisory board 
 20.34  created in section 62J.73, subdivision 4: 
 20.35     (1) a copy of the health plan company's form 990 filed with 
 20.36  the federal Internal Revenue Service; or 
 21.1      (2) if the health plan company did not file a form 990 with 
 21.2   the federal Internal Revenue Service, a list of the amount and 
 21.3   recipients of the health plan company's five highest salaries, 
 21.4   including all types of compensation, in excess of $50,000. 
 21.5      (b) A filing under this section is public data under 
 21.6   section 13.03. 
 21.7      Sec. 18.  [62Q.65] [CERTIFICATION; NO USE OF RELATED 
 21.8   ENTITIES TO EVADE STATE LAWS.] 
 21.9      (a) Each health plan company shall annually certify to the 
 21.10  commissioner that the health plan company and each of its 
 21.11  affiliates have, during the immediately preceding year, fully 
 21.12  complied with this act in connection with all health coverage 
 21.13  arrangements in this state for which the health plan company or 
 21.14  affiliate has acted as a health plan company, third party 
 21.15  administrator, preferred provider organization, utilization 
 21.16  review organization, or stop-loss coverage provider.  Compliance 
 21.17  with this act means compliance, in connection with all health 
 21.18  coverage arrangements, with all requirements that under this act 
 21.19  apply to health plans or health plan companies, regardless of 
 21.20  whether the health plan company or affiliate is acting as a 
 21.21  health plan company in connection with a particular health 
 21.22  coverage arrangement.  The certification must be filed with the 
 21.23  commissioner, on a form and date prescribed by the commissioner, 
 21.24  and not disapproved by the commissioner, as a condition of 
 21.25  continued licensure or certificate of authority. 
 21.26     (b) For purposes of this section: 
 21.27     (1) "commissioner," "health plan," and "health plan 
 21.28  company" have the meanings given in Minnesota Statutes, section 
 21.29  62Q.01; 
 21.30     (2) "affiliate" has the meaning given in Minnesota 
 21.31  Statutes, section 60D.15, subdivision 2; and 
 21.32     (3) "utilization review organization" has the meaning given 
 21.33  in Minnesota Statutes, section 62M.02, subdivision 21. 
 21.34     Sec. 19.  Minnesota Statutes 1996, section 181.932, 
 21.35  subdivision 1, is amended to read: 
 21.36     Subdivision 1.  [PROHIBITED ACTION.] An employer shall not 
 22.1   discharge, discipline, threaten, otherwise discriminate against, 
 22.2   or penalize an employee regarding the employee's compensation, 
 22.3   terms, conditions, location, or privileges of employment because:
 22.4      (a) the employee, or a person acting on behalf of an 
 22.5   employee, in good faith, reports a violation or suspected 
 22.6   violation of any federal or state law or rule adopted pursuant 
 22.7   to law to an employer or to any governmental body or law 
 22.8   enforcement official; 
 22.9      (b) the employee is requested by a public body or office to 
 22.10  participate in an investigation, hearing, inquiry; or 
 22.11     (c) the employee refuses an employer's order to perform an 
 22.12  action that the employee has an objective basis in fact to 
 22.13  believe violates any state or federal law or rule or regulation 
 22.14  adopted pursuant to law, and the employee informs the employer 
 22.15  that the order is being refused for that reason; or 
 22.16     (d) the employee, in good faith, reports a situation in 
 22.17  which the quality of the health care services provided by a 
 22.18  health care facility, organization, or health care provider 
 22.19  places the public at risk of harm.  
 22.20     Sec. 20.  [HEALTH COVERAGE COMPLAINT RESOLUTION; 
 22.21  SELF-INSURED PLANS.] 
 22.22     The commissioner of commerce shall apply to the United 
 22.23  States Department of Labor for authority to investigate and 
 22.24  resolve health coverage complaints of enrollees in self-insured 
 22.25  health plans, on substantially the same basis as the authority 
 22.26  granted to the Oklahoma insurance department. 
 22.27     Sec. 21.  [REPEALER.] 
 22.28     Minnesota Statutes 1996, sections 62J.2911; 62J.2912; 
 22.29  62J.2913; 62J.2914; 62J.2915; 62J.2916; 62J.2917; 62J.2918; 
 22.30  62J.2919; 62J.2920; 62J.2921; 62Q.105, subdivisions 2, 3, 4, and 
 22.31  8; and 62Q.11, are repealed. 
 22.32     Sec. 22.  [APPROPRIATION.] 
 22.33     $....... is appropriated from the general fund to the 
 22.34  commissioner of administration to contract for the operation of 
 22.35  the health care consumer assistance program established under 
 22.36  section 5.  The appropriation is available until expended. 
 23.1      Sec. 23.  [EFFECTIVE DATES.] 
 23.2      (a) Sections 1, 7, 10, and 20 are effective the day 
 23.3   following final enactment. 
 23.4      (b) Sections 2 to 4, 8, 12 to 15, 17, and 19 are effective 
 23.5   August 1, 1997. 
 23.6      (c) Section 5 is effective July 1, 1997, and the consumer 
 23.7   advisory board members must be appointed by that date.  The 
 23.8   health care consumer assistance program must be implemented by 
 23.9   January 1, 1998. 
 23.10     (d) Sections 6, 10, 11, and 16 are effective January 1, 
 23.11  1998. 
 23.12     (e) Section 18 is effective January 1, 1998, and the first 
 23.13  annual certification must cover the 1998 calendar year.