1.1                          A bill for an act
  1.2             relating to health; enhancing the patient protection 
  1.3             act; establishing the office of health care consumer 
  1.4             advocacy and information; appropriating money; 
  1.5             amending Minnesota Statutes 1996, section 62M.09, 
  1.6             subdivision 6; Minnesota Statutes 1997 Supplement, 
  1.7             sections 62J.70, subdivision 3; 62J.71, subdivisions 
  1.8             1, 3, and 4; 62J.72, subdivision 1; and 62M.09, 
  1.9             subdivision 3; proposing coding for new law in 
  1.10            Minnesota Statutes, chapter 62Q; repealing Minnesota 
  1.11            Statutes 1996, section 62Q.105, subdivisions 2, 3, 4, 
  1.12            5, 6, 7, and 8; Minnesota Statutes 1997 Supplement, 
  1.13            sections 62Q.105, subdivision 1; and 62Q.30. 
  1.14  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.15                             ARTICLE 1 
  1.16                PATIENT PROTECTION ACT ENHANCEMENTS 
  1.17     Section 1.  Minnesota Statutes 1997 Supplement, section 
  1.18  62J.70, subdivision 3, is amended to read: 
  1.19     Subd. 3.  [HEALTH PLAN COMPANY.] "Health plan company" 
  1.20  means a health plan company as defined in section 62Q.01, 
  1.21  subdivision 4, the medical assistance program, the MinnesotaCare 
  1.22  program, the general assistance medical care program, the state 
  1.23  employee group insurance program, the public employees insurance 
  1.24  program under section 43A.316, and coverage provided by 
  1.25  political subdivisions under section 471.617. 
  1.26     Sec. 2.  Minnesota Statutes 1997 Supplement, section 
  1.27  62J.71, subdivision 1, is amended to read: 
  1.28     Subdivision 1.  [PROHIBITED AGREEMENTS AND DIRECTIVES.] The 
  1.29  following types of agreements and directives are contrary to 
  2.1   state public policy, are prohibited under this section, and are 
  2.2   null and void: 
  2.3      (1) any agreement or directive that prohibits a health care 
  2.4   provider from communicating with an enrollee with respect to the 
  2.5   enrollee's health status, health care, or treatment options, if 
  2.6   the health care provider is acting in good faith and within the 
  2.7   provider's scope of practice as defined by law; 
  2.8      (2) any agreement or directive that prohibits a health care 
  2.9   provider from making a recommendation regarding the suitability 
  2.10  or desirability of a health plan company, health insurer, or 
  2.11  health coverage plan for an enrollee, unless the provider has a 
  2.12  financial conflict of interest in the enrollee's choice of 
  2.13  health plan company, health insurer, or health coverage plan; 
  2.14     (3) any agreement or directive that prohibits a provider 
  2.15  from providing testimony, supporting or opposing legislation, or 
  2.16  making any other contact with state or federal legislators or 
  2.17  legislative staff or with state and federal executive branch 
  2.18  officers or staff; 
  2.19     (4) any agreement or directive that prohibits a health care 
  2.20  provider from disclosing accurate information about whether 
  2.21  services or treatment will be paid for by a patient's health 
  2.22  plan company or health insurer or health coverage plan; and 
  2.23     (5) any agreement or directive that prohibits a health care 
  2.24  provider from informing an enrollee about the nature of the 
  2.25  reimbursement methodology used by an enrollee's health plan 
  2.26  company, health insurer, or health coverage plan to pay the 
  2.27  provider. 
  2.28     Sec. 3.  Minnesota Statutes 1997 Supplement, section 
  2.29  62J.71, subdivision 3, is amended to read: 
  2.30     Subd. 3.  [RETALIATION PROHIBITED.] No person, health plan 
  2.31  company, or other organization may take retaliatory action 
  2.32  against a health care provider solely on the grounds that the 
  2.33  provider: 
  2.34     (1) refused to enter into an agreement or provide services 
  2.35  or information in a manner that is prohibited under this section 
  2.36  or took any of the actions listed in subdivision 1; 
  3.1      (2) disclosed accurate information about whether a health 
  3.2   care service or treatment is covered by an enrollee's health 
  3.3   plan company, health insurer, or health coverage plan; or 
  3.4      (3) discussed diagnostic, treatment, or referral options 
  3.5   that are not covered or are limited by the enrollee's health 
  3.6   plan company, health insurer, or health coverage plan; 
  3.7      (4) criticized coverage or any other aspect of the 
  3.8   enrollee's health plan company, health insurer, or health 
  3.9   coverage plan; or 
  3.10     (5) expressed personal disagreement with a decision made by 
  3.11  a person, organization, or health care provider regarding 
  3.12  treatment or coverage provided to a patient of the provider, or 
  3.13  assisted or advocated for the patient in seeking reconsideration 
  3.14  of such a decision, provided the health care provider makes it 
  3.15  clear that the provider is acting in a personal capacity and not 
  3.16  as a representative of or on behalf of the entity that made the 
  3.17  decision. 
  3.18     Sec. 4.  Minnesota Statutes 1997 Supplement, section 
  3.19  62J.71, subdivision 4, is amended to read: 
  3.20     Subd. 4.  [EXCLUSION.] (a) Nothing in this section 
  3.21  prohibits a health plan an entity that is subject to this 
  3.22  section from taking action against a provider if the health plan 
  3.23  entity has evidence that the provider's actions are illegal, 
  3.24  constitute medical malpractice, or are contrary to accepted 
  3.25  medical practices. 
  3.26     (b) Nothing in this section prohibits a contract provision 
  3.27  or directive that requires any contracting party to keep 
  3.28  confidential or to not use or disclose the specific amounts paid 
  3.29  to a provider, provider fee schedules, provider salaries, and 
  3.30  other similar provider-specific proprietary information of a 
  3.31  specific health plan or health plan company entity that is 
  3.32  subject to this section.  
  3.33     Sec. 5.  Minnesota Statutes 1997 Supplement, section 
  3.34  62J.72, subdivision 1, is amended to read: 
  3.35     Subdivision 1.  [WRITTEN DISCLOSURE.] (a) A health plan 
  3.36  company, as defined under section 62J.70, subdivision 3, a 
  4.1   health care network cooperative as defined under section 62R.04, 
  4.2   subdivision 3, and a health care provider as defined under 
  4.3   section 62J.70, subdivision 2, shall, during open enrollment, 
  4.4   upon enrollment, and annually thereafter, provide enrollees with 
  4.5   a description of the general nature of the reimbursement 
  4.6   methodologies used by the health plan company, health insurer, 
  4.7   or health coverage plan to pay providers.  The description must 
  4.8   explain clearly any aspect of the reimbursement methodology that 
  4.9   in any way may tend to make it advantageous for the health care 
  4.10  provider to minimize or restrict the health care provided to 
  4.11  enrollees.  This description may be incorporated into the member 
  4.12  handbook, subscriber contract, certificate of coverage, or other 
  4.13  written enrollee communication.  The general reimbursement 
  4.14  methodology shall be made available to employers at the time of 
  4.15  open enrollment.  
  4.16     (b) Health plan companies, health care network 
  4.17  cooperatives, and providers must, upon request, provide an 
  4.18  enrollee with specific information regarding the reimbursement 
  4.19  methodology used by that health plan company or health care 
  4.20  network cooperative to reimburse a specific provider, including, 
  4.21  but not limited to, the following information:  
  4.22     (1) a concise written description of the provider payment 
  4.23  plan, including any incentive plan applicable to the enrollee; 
  4.24     (2) a written description of any incentive to the provider 
  4.25  relating to the provision of health care services to enrollees, 
  4.26  including any compensation arrangement that is dependent on the 
  4.27  amount of health coverage or health care services provided to 
  4.28  the enrollee, or the number of referrals to or utilization of 
  4.29  specialists; and 
  4.30     (3) a written description of any incentive plan that 
  4.31  involves the transfer of financial risk to the health care 
  4.32  provider. 
  4.33     (c) The disclosure statement describing the general nature 
  4.34  of the reimbursement methodologies must comply with the 
  4.35  Readability of Insurance Policies Act in chapter 72C.  
  4.36  Notwithstanding any other law to the contrary, the disclosure 
  5.1   statement may voluntarily be filed with the commissioner for 
  5.2   approval and must be filed with and approved by the commissioner 
  5.3   prior to its use. 
  5.4      (d) A disclosure statement that has voluntarily been filed 
  5.5   with the commissioner for approval under chapter 72C or 
  5.6   voluntarily filed with the commissioner for approval for 
  5.7   purposes other than pursuant to chapter 72C paragraph (c) is 
  5.8   deemed approved 30 days after the date of filing, unless 
  5.9   approved or disapproved by the commissioner on or before the end 
  5.10  of that 30-day period. 
  5.11     (e) The disclosure statement describing the general nature 
  5.12  of the reimbursement methodologies must be provided upon request 
  5.13  in English, Spanish, Vietnamese, and Hmong.  In addition, 
  5.14  reasonable efforts must be made to provide information contained 
  5.15  in the disclosure statement to other non-English-speaking 
  5.16  enrollees. 
  5.17     (f) Health plan companies and providers may enter into 
  5.18  agreements to determine how to respond to enrollee requests 
  5.19  received by either the provider or the health plan company.  
  5.20  This subdivision does not require disclosure of specific amounts 
  5.21  paid to a provider, provider fee schedules, provider salaries, 
  5.22  or other proprietary information of a specific health plan 
  5.23  company or health insurer or health coverage plan or provider. 
  5.24     Sec. 6.  Minnesota Statutes 1997 Supplement, section 
  5.25  62M.09, subdivision 3, is amended to read: 
  5.26     Subd. 3.  [PHYSICIAN REVIEWER INVOLVEMENT.] A physician 
  5.27  licensed in this state must review all cases involving enrollees 
  5.28  residing in Minnesota in which the utilization review 
  5.29  organization has concluded that a determination not to certify 
  5.30  for clinical reasons is appropriate.  The physician should be 
  5.31  reasonably available by telephone to discuss the determination 
  5.32  with the attending physician.  This subdivision does not apply 
  5.33  to outpatient mental health or substance abuse services governed 
  5.34  by subdivision 3a.  
  5.35     Sec. 7.  Minnesota Statutes 1996, section 62M.09, 
  5.36  subdivision 6, is amended to read: 
  6.1      Subd. 6.  [PHYSICIAN CONSULTANTS.] A utilization review 
  6.2   organization must use physician consultants in the appeal 
  6.3   process described in section 62M.06, subdivision 3, when 
  6.4   reviewing cases involving Minnesota enrollees.  The physician 
  6.5   consultants must be licensed in this state and should include, 
  6.6   as needed and available, specialists who are board-certified, or 
  6.7   board-eligible and working towards certification, in a specialty 
  6.8   board approved by the American Board of Medical Specialists or 
  6.9   the American Board of Osteopathy. 
  6.10     Sec. 8.  [62Q.107] [PROHIBITED PROVISION; EFFECT OF DENIAL 
  6.11  OF CLAIM.] 
  6.12     No health plan, including the coverages described in 
  6.13  section 62A.011, subdivision 3, clauses (7) and (10), may 
  6.14  contain a provision limiting the standard of review upon which a 
  6.15  court may review denial of a claim or of any other decision made 
  6.16  by a health plan company with respect to an enrollee.  This 
  6.17  section prohibits limiting court review to a determination of 
  6.18  whether the health plan company's decision is arbitrary and 
  6.19  capricious, an abuse of discretion, or any other standard less 
  6.20  favorable to the enrollee than a preponderance of the evidence.  
  6.21     Sec. 9.  [EFFECTIVE DATE.] 
  6.22     Sections 1 to 8 are effective January 1, 1999, and apply to 
  6.23  coverage issued, renewed, or continued as defined in section 
  6.24  60A.02, subdivision 2a, on or after that date. 
  6.25                             ARTICLE 2
  6.26           INDEPENDENT HEALTH COVERAGE DISPUTE RESOLUTION
  6.27     Section 1.  [62Q.108] [INDEPENDENT REVIEWS OF ADVERSE 
  6.28  DETERMINATIONS.] 
  6.29     Subdivision 1.  [DEFINITIONS.] (a) For purposes of this 
  6.30  section, the terms defined in this subdivision have the meanings 
  6.31  given them.  
  6.32     (b) "Adverse determination" means a determination by a 
  6.33  payer that the health care service, supplies, or equipment 
  6.34  furnished or proposed to be furnished to an enrollee are not 
  6.35  medically necessary. 
  6.36     (c) "Commissioner" means the commissioner of commerce or 
  7.1   the commissioner's designee. 
  7.2      (d) "Independent review organization" means a person 
  7.3   certified under this section. 
  7.4      (e) "Payer" means a health plan company as defined in 
  7.5   section 62Q.01, subdivision 4; the medical assistance, 
  7.6   MinnesotaCare, and general assistance medical care programs; the 
  7.7   state employees group insurance program; the public employees 
  7.8   insurance program; or a self-insured plan sponsored by a 
  7.9   political subdivision under section 471.617.  If a payer other 
  7.10  than a health plan company provides insured coverage to the 
  7.11  enrollee through a health plan company, the payer is the health 
  7.12  plan company. 
  7.13     Subd. 2.  [RIGHT TO INDEPENDENT REVIEW.] (a) An enrollee 
  7.14  who has received an adverse determination may obtain a review by 
  7.15  an independent review organization by making a written request 
  7.16  to the commissioner for an independent review under this section.
  7.17     (b) The commissioner shall promptly assign and transmit the 
  7.18  request to an independent review organization.  The assignment 
  7.19  of a request to an organization must be random, except that the 
  7.20  commissioner may take into account the capacity and areas of 
  7.21  expertise of the organizations. 
  7.22     (c) The enrollee shall pay with the request a review fee of 
  7.23  $25, which the commissioner shall transmit to the independent 
  7.24  review organization. 
  7.25     (d) The payer shall, promptly upon completion of the 
  7.26  review, pay to the independent review organization the remainder 
  7.27  of the review fee. 
  7.28     (e) The commissioner shall contract with one or more 
  7.29  independent review organizations certified under this section, 
  7.30  to perform independent reviews under this section.  The 
  7.31  contracted fees to be paid to independent review organizations 
  7.32  may, in the commissioner's discretion, vary between independent 
  7.33  review organizations, between the subject areas of reviews, and 
  7.34  between reviews that involve life-threatening conditions and 
  7.35  those that do not.  The commissioner shall ensure, to the extent 
  7.36  reasonably practicable, that the independent review 
  8.1   organizations contracted with together have a total capacity 
  8.2   adequate to fulfill the expected demand in a timely fashion. 
  8.3      Subd. 3.  [CERTIFICATION OF INDEPENDENT REVIEW 
  8.4   ORGANIZATIONS.] (a) The commissioner shall certify independent 
  8.5   review organizations as satisfying the requirements of this 
  8.6   section.  Persons wishing certification shall submit to the 
  8.7   commissioner an application for certification on a form 
  8.8   prescribed by the commissioner.  After certification, an 
  8.9   independent review organization shall promptly report to the 
  8.10  commissioner any changes in the information provided on the 
  8.11  application form.  The commissioner may suspend or revoke a 
  8.12  certification or take other disciplinary and enforcement actions 
  8.13  permitted under chapter 45.  The commissioner shall provide 
  8.14  ongoing oversight of the independent review organizations to 
  8.15  ensure their compliance with this section.  A certification must 
  8.16  be renewed every two years. 
  8.17     (b) The application required under paragraph (a) shall at a 
  8.18  minimum require the following information: 
  8.19     (1) the name and address of each owner of a greater than 
  8.20  five percent share of the applicant; 
  8.21     (2) the name and address of any holder of bonds, notes, or 
  8.22  other debt of the applicant in excess of $100,000; 
  8.23     (3) the name and type of business of each corporation or 
  8.24  other entity that is an affiliate, as defined in section 
  8.25  302A.011, subdivision 43, of the applicant, and the nature and 
  8.26  extent of the affiliation; 
  8.27     (4) the name, address, and a biographical sketch of each 
  8.28  officer and director of the applicant and of any entity 
  8.29  described in clause (3) and a description of any relationship 
  8.30  that the officer or director has or has had with a payer, health 
  8.31  care provider, utilization review organization under chapter 
  8.32  62M, or any association of those types of organizations; 
  8.33     (5) a description of the areas of expertise of the 
  8.34  physicians who will be making determinations for the applicant; 
  8.35     (6) the procedures that the applicant will use in 
  8.36  conducting independent reviews; and 
  9.1      (7) the percentage of the applicant's revenues that it 
  9.2   expects to derive from reviews under this section. 
  9.3      (c) Applicants for certification shall establish to the 
  9.4   commissioner's satisfaction that they will be able to comply 
  9.5   with the standards provided in subdivision 4. 
  9.6      (d) The commissioner shall maintain a list of certified 
  9.7   independent review organizations and publish the list at least 
  9.8   annually. 
  9.9      Subd. 4.  [STANDARDS FOR INDEPENDENT REVIEW 
  9.10  ORGANIZATIONS.] (a) An independent review organization must: 
  9.11     (1) consistently provide a response that is timely within 
  9.12  the requirements of this section; 
  9.13     (2) ensure confidentiality of medical records and other 
  9.14  enrollee information; 
  9.15     (3) provide reviews conducted by qualified and independent 
  9.16  physicians; 
  9.17     (4) use fair procedures in conducting reviews, including at 
  9.18  the request of the enrollee an opportunity for an informal 
  9.19  hearing in person or by telephone conference call; and 
  9.20     (5) provide timely notice to enrollees of the results of 
  9.21  the review, including the clinical basis for the determination. 
  9.22     (b) An independent review organization must not be a health 
  9.23  plan company or an affiliate, as defined in section 302A.011, 
  9.24  subdivision 43, of a health plan company. 
  9.25     Subd. 5.  [TIMELINESS REQUIREMENTS.] (a) An independent 
  9.26  review organization shall make, and send written notice of, its 
  9.27  determination no later than 15 business days after the 
  9.28  organization has received the information necessary to make its 
  9.29  determination.  The written notice shall be sent to the enrollee 
  9.30  and to the payer. 
  9.31     (b) The payer shall provide to the independent review 
  9.32  organization any materials that it wishes the organization to 
  9.33  consider no later than ten business days after receiving notice 
  9.34  of the review from the independent review organization. 
  9.35     (c) The enrollee shall provide to the independent review 
  9.36  organization any materials that the enrollee wishes the 
 10.1   organization to consider.  The independent review organization 
 10.2   shall not begin to conduct the review until the enrollee states 
 10.3   in writing that the enrollee has provided all such materials. 
 10.4      (d) In the case of a life-threatening condition, an 
 10.5   independent review organization shall make its determination no 
 10.6   later than five business days after the organization has 
 10.7   received all information necessary to make its determination.  
 10.8   The time period provided under paragraph (b) shall be three 
 10.9   business days under this paragraph.  The organization shall 
 10.10  provide immediate notice by telephone or facsimile and provide 
 10.11  written notice by mail.  "Life-threatening condition" means a 
 10.12  disease or other medical condition that will probably result in 
 10.13  death unless the course of the disease or condition is 
 10.14  interrupted within a period of time that is shorter than the 
 10.15  time frame consistent with paragraphs (a) and (b). 
 10.16     Subd. 6.  [EFFECTS OF REVIEW.] (a) An enrollee's decision 
 10.17  to exercise the enrollee's rights under this section does not 
 10.18  affect any other rights of the enrollee to appeal or otherwise 
 10.19  contest an adverse determination.  A determination under this 
 10.20  section is not admissible in a court of law. 
 10.21     (b) An independent review organization is not liable to the 
 10.22  enrollee, the payer, or anyone else for a determination made 
 10.23  under this section. 
 10.24     Sec. 2.  [REPEALER.] 
 10.25     Minnesota Statutes 1996, section 62Q.105, subdivisions 2, 
 10.26  3, 4, 5, 6, 7, and 8; and Minnesota Statutes 1997 Supplement, 
 10.27  sections 62Q.105, subdivision 1; and 62Q.30, are repealed. 
 10.28     Sec. 3.  [EFFECTIVE DATE.] 
 10.29     Section 1 is effective January 1, 1999, and applies to 
 10.30  coverage issued or renewed on or after that date.  With respect 
 10.31  to responsibilities of the commissioner of commerce necessary to 
 10.32  carry out section 1, section 1 is effective the day following 
 10.33  final enactment.  Section 2 is effective the day following final 
 10.34  enactment.