1.1                          A bill for an act 
  1.2             relating to health; providing for certain patient 
  1.3             rights and protections; amending Minnesota Statutes 
  1.4             1998, sections 62D.07, subdivision 3; 62D.11, 
  1.5             subdivision 1; 62J.451, subdivision 6a; 62J.71, 
  1.6             subdivision 1; 62J.72, subdivision 1; 62J.80; 62M.05, 
  1.7             subdivisions 1, 3, and by adding subdivisions; 62M.06, 
  1.8             by adding a subdivision; 62Q.10; 62Q.105, subdivisions 
  1.9             3, 7, and by adding a subdivision; 62Q.106; 62Q.19, 
  1.10            subdivision 5a; 62Q.55; 62Q.56, subdivision 1, and by 
  1.11            adding subdivisions; 72A.201, subdivision 4a; and 
  1.12            256B.692, subdivision 2; proposing coding for new law 
  1.13            in Minnesota Statutes, chapters 62J; 62M; and 62Q; 
  1.14            repealing Minnesota Statutes 1998, sections 62J.42; 
  1.15            62Q.105, subdivision 4; 62Q.11; 62Q.30; 62Q.51, 
  1.16            subdivision 4; and 62Q.58.  
  1.17  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.18     Section 1.  Minnesota Statutes 1998, section 62D.07, 
  1.19  subdivision 3, is amended to read: 
  1.20     Subd. 3.  Contracts and evidences of coverage shall contain:
  1.21     (a) No provisions or statements which are unjust, unfair, 
  1.22  inequitable, misleading, deceptive, or which are untrue, 
  1.23  misleading, or deceptive as defined in section 62D.12, 
  1.24  subdivision 1; 
  1.25     (b) A clear, concise and complete statement of: 
  1.26     (1) the health care services and the insurance or other 
  1.27  benefits, if any, to which the enrollee is entitled under the 
  1.28  health maintenance contract information required under section 
  1.29  62Q.70; 
  1.30     (2) any exclusions or limitations on the services, kind of 
  1.31  services, benefits, or kind of benefits, to be provided, 
  2.1   including any deductible or copayment feature and requirements 
  2.2   for referrals, prior authorizations, and second opinions; 
  2.3      (3) where and in what manner information is available as to 
  2.4   how services, including emergency and out of area services, may 
  2.5   be obtained; 
  2.6      (4) (2) the total amount of payment and copayment, if any, 
  2.7   for health care services and the indemnity or service benefits, 
  2.8   if any, which the enrollee is obligated to pay with respect to 
  2.9   individual contracts, or an indication whether the plan is 
  2.10  contributory or noncontributory with respect to group 
  2.11  certificates; and 
  2.12     (5) (3) a description of the health maintenance 
  2.13  organization's method for resolving enrollee complaints and a 
  2.14  statement identifying the commissioner as an external source 
  2.15  with whom complaints may be registered; and 
  2.16     (c) On the cover page of the evidence of coverage and 
  2.17  contract, a clear and complete statement of enrollees' rights.  
  2.18  The statement must be in bold print and captioned "Important 
  2.19  Enrollee Information and Enrollee Bill of Rights" and must 
  2.20  include but not be limited to the following provisions in the 
  2.21  following language or in substantially similar language approved 
  2.22  in advance by the commissioner, except that paragraph (8) does 
  2.23  not apply to prepaid health plans providing coverage for 
  2.24  programs administered by the commissioner of human services:  
  2.25                        ENROLLEE INFORMATION 
  2.26     (1) COVERED SERVICES:  Services provided by (name of health 
  2.27  maintenance organization) will be covered only if services are 
  2.28  provided by participating (name of health maintenance 
  2.29  organization) providers or authorized by (name of health 
  2.30  maintenance organization).  Your contract fully defines what 
  2.31  services are covered and describes procedures you must follow to 
  2.32  obtain coverage. 
  2.33     (2) PROVIDERS:  Enrolling in (name of health maintenance 
  2.34  organization) does not guarantee services by a particular 
  2.35  provider on the list of providers.  When a provider is no longer 
  2.36  part of (name of health maintenance organization), you must 
  3.1   choose among remaining (name of the health maintenance 
  3.2   organization) providers. 
  3.3      (3) REFERRALS:  Certain services are covered only upon 
  3.4   referral.  See section (section number) of your contract for 
  3.5   referral requirements.  All referrals to non-(name of health 
  3.6   maintenance organization) providers and certain types of health 
  3.7   care providers must be authorized by (name of health maintenance 
  3.8   organization). 
  3.9      (4) EMERGENCY SERVICES:  Emergency services from providers 
  3.10  who are not affiliated with (name of health maintenance 
  3.11  organization) will be covered only if proper procedures are 
  3.12  followed.  Your contract explains the procedures and benefits 
  3.13  associated with emergency care from (name of health maintenance 
  3.14  organization) and non-(name of health maintenance organization) 
  3.15  providers. 
  3.16     (5) EXCLUSIONS:  Certain services or medical supplies are 
  3.17  not covered.  You should read the contract for a detailed 
  3.18  explanation of all exclusions. 
  3.19     (6) CONTINUATION:  You may convert to an individual health 
  3.20  maintenance organization contract or continue coverage under 
  3.21  certain circumstances.  These continuation and conversion rights 
  3.22  are explained fully in your contract. 
  3.23     (7) CANCELLATION:  Your coverage may be canceled by you or 
  3.24  (name of health maintenance organization) only under certain 
  3.25  conditions.  Your contract describes all reasons for 
  3.26  cancellation of coverage. 
  3.27     (8) NEWBORN COVERAGE:  If your health plan provides for 
  3.28  dependent coverage, a newborn infant is covered from birth, but 
  3.29  only if services are provided by participating (name of health 
  3.30  maintenance organization) providers or authorized by (name of 
  3.31  health maintenance organization).  Certain services are covered 
  3.32  only upon referral.  (Name of health maintenance organization) 
  3.33  will not automatically know of the infant's birth or that you 
  3.34  would like coverage under your plan.  You should notify (name of 
  3.35  health maintenance organization) of the infant's birth and that 
  3.36  you would like coverage.  If your contract requires an 
  4.1   additional premium for each dependent, (name of health 
  4.2   maintenance organization) is entitled to all premiums due from 
  4.3   the time of the infant's birth until the time you notify (name 
  4.4   of health maintenance organization) of the birth.  (Name of 
  4.5   health maintenance organization) may withhold payment of any 
  4.6   health benefits for the newborn infant until any premiums you 
  4.7   owe are paid. 
  4.8      (9) PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT:  Enrolling in 
  4.9   (name of health maintenance organization) does not guarantee 
  4.10  that any particular prescription drug will be available nor that 
  4.11  any particular piece of medical equipment will be available, 
  4.12  even if the drug or equipment is available at the start of the 
  4.13  contract year. 
  4.14                      ENROLLEE BILL OF RIGHTS 
  4.15     (1) Enrollees have the right to available and accessible 
  4.16  services including, but not limited to, emergency services, as 
  4.17  defined in your the health plan contract, 24 hours a day and 
  4.18  seven days a week; 
  4.19     (2) Enrollees have the right to be informed of health 
  4.20  problems, and to receive information regarding treatment 
  4.21  alternatives and risks which is sufficient to assure informed 
  4.22  choice; 
  4.23     (3) Enrollees have the right to refuse treatment, and the 
  4.24  right to privacy of medical and financial records maintained by 
  4.25  the health maintenance organization and its health care 
  4.26  providers, in accordance with existing law; 
  4.27     (4) Enrollees have the right to file a complaint with the 
  4.28  health maintenance organization and the commissioner of health, 
  4.29  the right to appeal a decision, and the right to initiate a 
  4.30  legal proceeding when experiencing a problem with the health 
  4.31  maintenance organization or its health care providers; 
  4.32     (5) Enrollees have the right to a grace period of 31 days 
  4.33  for the payment of each premium for an individual health 
  4.34  maintenance contract falling due after the first premium during 
  4.35  which period the contract shall continue in force; 
  4.36     (6) Enrollees have the right to have all billings suspended 
  5.1   during the complaint or appeal process for those services 
  5.2   questioned in the complaint or appeal; 
  5.3      (7) Medicare enrollees have the right to voluntarily 
  5.4   disenroll from the health maintenance organization and the right 
  5.5   not to be requested or encouraged to disenroll except in 
  5.6   circumstances specified in federal law; and 
  5.7      (7) (8) Medicare enrollees have the right to a clear 
  5.8   description of nursing home and home care benefits covered by 
  5.9   the health maintenance organization. 
  5.10     Sec. 2.  Minnesota Statutes 1998, section 62D.11, 
  5.11  subdivision 1, is amended to read: 
  5.12     Subdivision 1.  [ENROLLEE COMPLAINT SYSTEM.] Every health 
  5.13  maintenance organization shall establish and maintain a 
  5.14  complaint system, as required under section 62Q.105 to provide 
  5.15  reasonable procedures for the resolution of written complaints 
  5.16  initiated by or on behalf of enrollees concerning the provision 
  5.17  of health care services.  "Provision of health services" 
  5.18  includes, but is not limited to, questions of the scope of 
  5.19  coverage, quality of care, and administrative operations.  The 
  5.20  health maintenance organization must inform enrollees that they 
  5.21  may choose to use arbitration an external appeals process under 
  5.22  section 62Q.109 to appeal a health maintenance organization's 
  5.23  internal appeal decision.  The health maintenance organization 
  5.24  must also inform enrollees that they have the right to 
  5.25  use arbitration an external appeals process to appeal a health 
  5.26  maintenance organization's internal appeal decision not to 
  5.27  certify an admission, procedure, service, or extension of stay 
  5.28  under section 62M.06.  If an enrollee chooses to use arbitration 
  5.29  an external appeals process, the health maintenance organization 
  5.30  must participate. 
  5.31     Sec. 3.  Minnesota Statutes 1998, section 62J.451, 
  5.32  subdivision 6a, is amended to read: 
  5.33     Subd. 6a.  [HEALTH PLAN COMPANY PERFORMANCE MEASUREMENT.] 
  5.34  As part of the performance measurement plan specified in 
  5.35  subdivision 6, the health data institute shall develop a 
  5.36  mechanism to assess the performance of health plan companies, 
  6.1   and to disseminate this information through reports and other 
  6.2   means to consumers, purchasers, policymakers, and other 
  6.3   interested parties, consistent with the data policies specified 
  6.4   in section 62J.452.  At a minimum, the health data institute 
  6.5   shall collect: 
  6.6      (1) aggregate utilization data; 
  6.7      (2) data on the demographic characteristics of enrollees; 
  6.8      (3) data on disease-specific and age-specific mortality 
  6.9   rates and morbidity rates; 
  6.10     (4) data on enrollee satisfaction, including data on 
  6.11  voluntary disenrollment and complaints; and 
  6.12     (5) data on quality indicators and health outcomes, 
  6.13  including pediatric and gender-specific data. 
  6.14     Sec. 4.  Minnesota Statutes 1998, section 62J.71, 
  6.15  subdivision 1, is amended to read: 
  6.16     Subdivision 1.  [PROHIBITED AGREEMENTS AND DIRECTIVES.] The 
  6.17  following types of agreements and directives are contrary to 
  6.18  state public policy, are prohibited under this section, and are 
  6.19  null and void: 
  6.20     (1) any agreement or directive that prohibits a health care 
  6.21  provider from communicating with an enrollee with respect to the 
  6.22  enrollee's health status, health care, or treatment options, if 
  6.23  the health care provider is acting in good faith and within the 
  6.24  provider's scope of practice as defined by law; 
  6.25     (2) any agreement or directive that prohibits a health care 
  6.26  provider from making a recommendation regarding the suitability 
  6.27  or desirability of a health plan company, health insurer, or 
  6.28  health coverage plan for an enrollee, unless the provider has a 
  6.29  financial conflict of interest in the enrollee's choice of 
  6.30  health plan company, health insurer, or health coverage plan; 
  6.31     (3) any agreement or directive that prohibits a provider 
  6.32  from providing testimony, supporting or opposing legislation, or 
  6.33  making any other contact with state or federal legislators or 
  6.34  legislative staff or with state and federal executive branch 
  6.35  officers or staff; 
  6.36     (4) any agreement or directive that prohibits a health care 
  7.1   provider from disclosing accurate information about whether 
  7.2   services or treatment will be paid for by a patient's health 
  7.3   plan company or health insurer or health coverage plan; and 
  7.4      (5) any agreement or directive that prohibits a health care 
  7.5   provider from informing an enrollee about the nature of the 
  7.6   reimbursement methodology used by an enrollee's health plan 
  7.7   company, health insurer, or health coverage plan to pay the 
  7.8   provider.; 
  7.9      (6) any agreement or directive that purports to transfer to 
  7.10  a health care provider by indemnification or otherwise any 
  7.11  liability relating to the activities, actions, or omissions of a 
  7.12  health plan company; and 
  7.13     (7) any agreement or directive that constitutes a physician 
  7.14  incentive plan prohibited under United States Code, title 42, 
  7.15  section 1395mm, paragraph (i), clause (8). 
  7.16     Sec. 5.  Minnesota Statutes 1998, section 62J.72, 
  7.17  subdivision 1, is amended to read: 
  7.18     Subdivision 1.  [WRITTEN DISCLOSURE.] (a) A health plan 
  7.19  company, as defined under section 62J.70, subdivision 3, a 
  7.20  health care network cooperative as defined under section 62R.04, 
  7.21  subdivision 3, and a health care provider as defined under 
  7.22  section 62J.70, subdivision 2, shall, during open enrollment, 
  7.23  upon enrollment, and annually thereafter, provide enrollees with 
  7.24  a description of the general nature of the reimbursement 
  7.25  methodologies used by the health plan company, health insurer, 
  7.26  or health coverage plan to pay providers.  The description must 
  7.27  explain clearly any aspect of the reimbursement methodology that 
  7.28  creates a financial incentive for the health care provider to 
  7.29  limit or restrict the health care, including, but not limited 
  7.30  to, acute and chronic care, provided to enrollees.  An entity 
  7.31  required to disclose shall also disclose if no reimbursement 
  7.32  methodology is used that creates a financial incentive for the 
  7.33  health care provider to limit or restrict the health care 
  7.34  provided to enrollees.  This description may be incorporated 
  7.35  into the member handbook, subscriber contract, certificate of 
  7.36  coverage, or other written enrollee communication.  The general 
  8.1   reimbursement methodology shall be made available to employers 
  8.2   at the time of open enrollment.  
  8.3      (b) Health plan companies, health care network 
  8.4   cooperatives, and providers must, upon request, provide an 
  8.5   enrollee with specific information regarding the reimbursement 
  8.6   methodology, including, but not limited to, the following 
  8.7   information:  
  8.8      (1) a concise written description of the provider payment 
  8.9   plan, including any incentive plan applicable to the enrollee; 
  8.10     (2) a written description of any incentive to the provider 
  8.11  relating to the provision of health care services to enrollees, 
  8.12  including any compensation arrangement that is dependent on the 
  8.13  amount of health coverage or health care services provided to 
  8.14  the enrollee, or the number of referrals to or utilization of 
  8.15  specialists; and 
  8.16     (3) a written description of any incentive plan that 
  8.17  involves the transfer of financial risk to the health care 
  8.18  provider. 
  8.19     (c) The disclosure statement describing the general nature 
  8.20  of the reimbursement methodologies must comply with the 
  8.21  Readability of Insurance Policies Act in chapter 72C and must be 
  8.22  filed with and approved by the commissioner prior to its use. 
  8.23     (d) A disclosure statement that has been filed with the 
  8.24  commissioner for approval under paragraph (c) is deemed approved 
  8.25  30 days after the date of filing, unless approved or disapproved 
  8.26  by the commissioner on or before the end of that 30-day period. 
  8.27     (e) The disclosure statement describing the general nature 
  8.28  of the reimbursement methodologies must be provided upon request 
  8.29  in English, Spanish, Vietnamese, and Hmong.  In addition, 
  8.30  reasonable efforts must be made to provide information contained 
  8.31  in the disclosure statement to other non-English-speaking 
  8.32  enrollees. 
  8.33     (f) Health plan companies and providers may enter into 
  8.34  agreements to determine how to respond to enrollee requests 
  8.35  received by either the provider or the health plan company.  
  8.36  This subdivision does not require disclosure of specific amounts 
  9.1   paid to a provider, provider fee schedules, provider salaries, 
  9.2   or other proprietary information of a specific health plan 
  9.3   company or health insurer or health coverage plan or provider. 
  9.4      Sec. 6.  [62J.725] [PROMOTING GOOD MEDICAL PRACTICE.] 
  9.5      Subdivision 1.  [INTERFERENCE PROHIBITED.] A health plan 
  9.6   company may not arbitrarily interfere with or alter the decision 
  9.7   of a treating physician regarding the manner or setting in which 
  9.8   a particular service is delivered for treatment or diagnosis if 
  9.9   the service is medically necessary or appropriate as determined 
  9.10  by the enrollee and the enrollee's physician, to the extent that 
  9.11  the treatment or diagnosis is otherwise a covered benefit. 
  9.12     Subd. 2.  [CONSTRUCTION.] (a) Nothing in this section shall 
  9.13  be construed as prohibiting a health plan company from limiting 
  9.14  the delivery of services to one or more health care providers 
  9.15  within a preferred provider network. 
  9.16     (b) Nothing in this section shall be construed to require 
  9.17  coverage of a particular service when coverage is not otherwise 
  9.18  provided under the health plan or to preclude a utilization 
  9.19  review under chapter 62M. 
  9.20     Sec. 7.  Minnesota Statutes 1998, section 62J.80, is 
  9.21  amended to read: 
  9.22     62J.80 [RETALIATION.] 
  9.23     Subdivision 1.  [COMPLAINTS.] A health plan company or 
  9.24  health care provider shall not retaliate or take adverse action 
  9.25  against an enrollee or, patient, or health care provider who, in 
  9.26  good faith, makes a complaint against a health plan company or 
  9.27  health care provider participates in a utilization review under 
  9.28  chapter 62M or a complaint process or internal or external 
  9.29  review or appeals process under chapter 62Q.  If retaliation is 
  9.30  suspected, the executive director may report it to the 
  9.31  appropriate regulatory authority.  
  9.32     Subd. 2.  [INVESTIGATION.] A health plan company or health 
  9.33  care provider shall not retaliate or discriminate against a 
  9.34  health care provider who, in good faith: 
  9.35     (1) discloses information relating to the care, services, 
  9.36  or conditions affecting an enrollee to an appropriate public 
 10.1   regulatory agency, private accreditation body, or management 
 10.2   personnel of the health plan company; or 
 10.3      (2) initiates, cooperates, or otherwise participates in an 
 10.4   investigation or proceeding by a public regulatory agency. 
 10.5      Sec. 8.  Minnesota Statutes 1998, section 62M.05, 
 10.6   subdivision 1, is amended to read: 
 10.7      Subdivision 1.  [WRITTEN PROCEDURES GENERAL 
 10.8   REQUIREMENTS.] (a) A utilization review organization must have 
 10.9   written procedures to ensure that reviews are conducted in 
 10.10  accordance with the requirements of this chapter and section 
 10.11  72A.201, subdivision 4a. 
 10.12     (b) Notwithstanding section 62M.125, a utilization review 
 10.13  organization must consult the patient's attending physician or 
 10.14  health care provider when conducting utilization review. 
 10.15     (c) The claims administrator or other representative of the 
 10.16  health benefit plan that denied coverage has the burden of 
 10.17  proving that the health care service should not be certified. 
 10.18     Sec. 9.  Minnesota Statutes 1998, section 62M.05, 
 10.19  subdivision 3, is amended to read: 
 10.20     Subd. 3.  [NOTIFICATION OF DETERMINATIONS.] A utilization 
 10.21  review organization must have written procedures for providing 
 10.22  notification of its determinations on all certifications in 
 10.23  accordance with the following: 
 10.24     (a) When an initial determination is made to certify, 
 10.25  notification must be provided promptly by telephone to the 
 10.26  provider according to paragraph (c).  The utilization review 
 10.27  organization shall send written notification to the hospital, 
 10.28  attending physician, or applicable service provider within ten 
 10.29  business days of the determination in accordance with section 
 10.30  72A.201, subdivision 4a, or and the enrollee according to 
 10.31  paragraph (c).  The utilization review organization shall 
 10.32  maintain an audit trail of the determination and telephone 
 10.33  notification.  For purposes of this subdivision, "audit trail" 
 10.34  includes documentation of the telephone notification, including 
 10.35  the date; the name of the person spoken to; the enrollee or 
 10.36  patient; the service, procedure, or admission certified; and the 
 11.1   date of the service, procedure, or admission.  If the 
 11.2   utilization review organization indicates certification by use 
 11.3   of a number, the number must be called the "certification 
 11.4   number." 
 11.5      (b) When a determination is made not to certify a hospital 
 11.6   or surgical facility admission or extension of a hospital stay, 
 11.7   or other service requiring review determination, within one 
 11.8   working day after making the decision the attending physician 
 11.9   and hospital must be notified by telephone and a written 
 11.10  notification must be sent to the hospital, attending physician, 
 11.11  and enrollee or patient.  The written notification must include 
 11.12  the principal reason or reasons for the determination and the 
 11.13  process for initiating an appeal of the determination.  Upon 
 11.14  request, the utilization review organization shall provide the 
 11.15  attending physician or, provider, or enrollee with the criteria 
 11.16  used to determine the necessity, appropriateness, and efficacy 
 11.17  of the health care service and identify the database, 
 11.18  professional treatment parameter, or other basis for the 
 11.19  criteria.  Reasons for a determination not to certify may 
 11.20  include, among other things, the lack of adequate information to 
 11.21  certify after a reasonable attempt has been made to contact the 
 11.22  attending physician. 
 11.23     (c) When an initial determination is made to certify, the 
 11.24  utilization review organization shall provide notice according 
 11.25  to this paragraph: 
 11.26     (1) In the case of utilization review involving prior 
 11.27  authorization of services, the utilization review organization 
 11.28  shall provide notice as soon as possible according to medical 
 11.29  exigencies of the case and in no event later than three business 
 11.30  days after the date of receipt of information that is necessary 
 11.31  to make the determination. 
 11.32     (2) In the case of a utilization review involving 
 11.33  authorization for continued or extended health care services or 
 11.34  additional services for an enrollee undergoing a course of 
 11.35  continued treatment prescribed by a provider, the utilization 
 11.36  review organization shall provide notice as soon as possible 
 12.1   according to medical exigencies of the case and in no event 
 12.2   later than one business day after the date of receipt of 
 12.3   information that is necessary to make the determination.  
 12.4   Notification regarding continued or extended health care 
 12.5   services must specify the number of extended services approved, 
 12.6   the new total of approved services, the date of onset of 
 12.7   services, and the new review date, if any. 
 12.8      (3) In the case of a utilization review involving 
 12.9   retrospective review of health care services previously 
 12.10  provided, the utilization review organization shall provide 
 12.11  notice within 30 days of the date of receipt of information that 
 12.12  is necessary to make the determination.  
 12.13     Sec. 10.  Minnesota Statutes 1998, section 62M.05, is 
 12.14  amended by adding a subdivision to read: 
 12.15     Subd. 5.  [CONTINUING USE OF STANDARDS IN RETROSPECTIVE 
 12.16  REVIEW.] If a health care service is certified for an enrollee 
 12.17  under written clinical criteria and review procedures according 
 12.18  to section 62M.09, subdivision 5, the utilization review 
 12.19  organization shall not, pursuant to retrospective review, revise 
 12.20  or modify the specific standards, criteria, or procedures used 
 12.21  for the utilization review of health care services delivered to 
 12.22  the enrollee during the same course of treatment.  
 12.23     Sec. 11.  Minnesota Statutes 1998, section 62M.05, is 
 12.24  amended by adding a subdivision to read: 
 12.25     Subd. 6.  [LIMITS ON FREQUENCY.] A utilization review 
 12.26  organization shall not undertake utilization review with respect 
 12.27  to a class of services furnished to an individual more 
 12.28  frequently than is reasonably required to assess whether the 
 12.29  services under review are medically necessary or appropriate, as 
 12.30  determined by the enrollee and the enrollee's physician.  
 12.31     Sec. 12.  Minnesota Statutes 1998, section 62M.05, is 
 12.32  amended by adding a subdivision to read: 
 12.33     Subd. 7.  [REVIEW OF DECISION.] An enrollee who is 
 12.34  dissatisfied with a decision of a utilization review 
 12.35  organization must have an opportunity to discuss the decision 
 12.36  with, and have the decision reviewed by, the medical director of 
 13.1   the organization or other individual who has the authority to 
 13.2   reverse the decision.  
 13.3      Sec. 13.  Minnesota Statutes 1998, section 62M.06, is 
 13.4   amended by adding a subdivision to read: 
 13.5      Subd. 5.  [EXTERNAL APPEAL.] (a) A utilization review 
 13.6   organization must have written procedures for independent 
 13.7   external appeals of determinations not to certify an admission, 
 13.8   procedure, service, or extension of stay.  A utilization review 
 13.9   organization may condition the use of the external appeals 
 13.10  process on completion of an internal appeals process under 
 13.11  subdivisions 1 to 3. 
 13.12     (b) The external appeals process must utilize an external 
 13.13  appeal entity certified under section 62Q.1093 and must comply 
 13.14  with section 62Q.109, subdivision 4.  
 13.15     Sec. 14.  [62M.125] [PROHIBITION OF CONFLICTS.] 
 13.16     A utilization review organization shall not permit a health 
 13.17  care professional who provides health care services to an 
 13.18  individual to perform utilization review in connection with the 
 13.19  health care services provided to that individual.  
 13.20     Sec. 15.  [62Q.092] [ADEQUACY OF PROVIDER NETWORK.] 
 13.21     Subdivision 1.  [PARTICIPATING PROVIDERS.] A health plan 
 13.22  company that provides benefits, in whole or in part, through a 
 13.23  preferred provider network shall have a sufficient number, 
 13.24  distribution, and variety of qualified participating health care 
 13.25  providers to ensure that all covered health care services, 
 13.26  including specialty services, are available and accessible in a 
 13.27  timely manner to all enrollees. 
 13.28     Subd. 2.  [TREATMENT OF CERTAIN PROVIDERS.] The qualified 
 13.29  health care providers under subdivision 1 may include federally 
 13.30  qualified health centers, rural health clinics, migrant health 
 13.31  centers, and other essential community providers located in the 
 13.32  service area of a health plan and shall include these providers 
 13.33  if necessary to meet the standard established under subdivision 
 13.34  1.  
 13.35     Sec. 16.  [62Q.093] [CHOICE OF PROVIDERS.] 
 13.36     Subdivision 1.  [PRIMARY CARE.] A health plan company shall 
 14.1   permit an enrollee to receive primary care from any 
 14.2   participating primary care provider who is available to accept 
 14.3   the individual. 
 14.4      Subd. 2.  [SPECIALISTS.] (a) A health plan company shall 
 14.5   permit an enrollee to receive medically necessary or appropriate 
 14.6   specialty care, pursuant to appropriate referral procedures, 
 14.7   from any qualified participating health care provider who is 
 14.8   available to accept the individual for specialty care. 
 14.9      (b) Paragraph (a) does not apply to specialty care if the 
 14.10  health plan company clearly informs enrollees of the limitations 
 14.11  on choice of participating providers with respect to specialty 
 14.12  care.  
 14.13     Sec. 17.  Minnesota Statutes 1998, section 62Q.10, is 
 14.14  amended to read: 
 14.15     62Q.10 [NONDISCRIMINATION SELECTION OF PROVIDERS.] 
 14.16     Subdivision 1.  [WRITTEN SELECTION PROCESS.] A health plan 
 14.17  company that provides benefits through a preferred provider 
 14.18  network shall have a written process for the selection of 
 14.19  participating providers.  The process must: 
 14.20     (1) specify minimum professional requirements; 
 14.21     (2) require verification of a health care provider's 
 14.22  license and any history of suspension or revocation; 
 14.23     (3) provide notice of the rules regarding participation in 
 14.24  the preferred provider network; 
 14.25     (4) provide written notice of preferred provider status 
 14.26  decisions that are adverse to health care providers; and 
 14.27     (5) provide a process within the health plan company for 
 14.28  appealing an adverse decision regarding preferred provider 
 14.29  status, including, but not limited to, the presentation of 
 14.30  information and views of the health care provider regarding the 
 14.31  decision. 
 14.32     Subd. 2.  [PROHIBITED EXCLUSION.] The selection process 
 14.33  under subdivision 1 may not use a high-risk patient base or the 
 14.34  location of a health care provider in an area with residents 
 14.35  with poorer health status as a basis for denying preferred 
 14.36  provider network status. 
 15.1      Subd. 3.  [NONDISCRIMINATION.] (a) If a health plan 
 15.2   company, with the exception of a community integrated service 
 15.3   network or an indemnity insurer licensed under chapter 60A who 
 15.4   does not offer a product through a preferred provider network, 
 15.5   offers coverage of a health care service as part of its plan, it 
 15.6   may not deny provider network status to a qualified health care 
 15.7   provider type who meets the credentialing requirements of the 
 15.8   health plan company solely because the provider is an allied 
 15.9   independent health care provider as defined in section 62Q.095. 
 15.10     (b) The selection process shall not discriminate with 
 15.11  respect to participation in a preferred provider network or 
 15.12  indemnification as to any health care provider who is acting 
 15.13  within the scope of the provider's license or certification 
 15.14  under applicable law, solely on the basis of the license or 
 15.15  certification.  
 15.16     (c) The selection process shall not discriminate with 
 15.17  respect to selection of a health care professional to be a 
 15.18  participating provider, or with respect to the terms and 
 15.19  conditions of participation, based on the professional's race, 
 15.20  color, religion, sex, national origin, age, sexual orientation, 
 15.21  or disability. 
 15.22     Subd. 4.  [CONSTRUCTION.] This section shall not be 
 15.23  construed: 
 15.24     (1) to require coverage of particular benefits under a 
 15.25  health plan; 
 15.26     (2) to prohibit a health plan company from including 
 15.27  providers only to the extent necessary to meet the needs of a 
 15.28  health plan's enrollees; 
 15.29     (3) to prohibit a health plan company from establishing any 
 15.30  measure designed to maintain quality and control costs; or 
 15.31     (4) to preempt state licensing or scope-of-practice law.  
 15.32     Sec. 18.  [62Q.103] [MEDICAL CONSULTATION REQUIRED.] 
 15.33     A health plan company shall consult with participating 
 15.34  physicians, if any, regarding the health plan company's medical 
 15.35  policy, quality, and medical management procedures. 
 15.36     Sec. 19.  Minnesota Statutes 1998, section 62Q.105, is 
 16.1   amended by adding a subdivision to read: 
 16.2      Subd. 1a.  [SCOPE; REQUIREMENTS.] (a) The complaint 
 16.3   resolution process must address complaints regarding access to 
 16.4   and availability of services, quality of care, choice and 
 16.5   accessibility of providers, network adequacy, and compliance 
 16.6   with the requirements of this chapter. 
 16.7      (b) A health plan company must provide in writing to 
 16.8   enrollees and participating providers the telephone numbers and 
 16.9   addresses of health plan company personnel who are responsible 
 16.10  for the resolution of complaints and appeals. 
 16.11     (c) A health plan company must establish procedures for 
 16.12  follow-up action for complaints, including, but not limited to, 
 16.13  a method of informing an enrollee who makes a complaint of the 
 16.14  resolution of the complaint.  
 16.15     (d) During a complaint resolution process, a health plan 
 16.16  company shall suspend billings to the enrollee, if applicable, 
 16.17  for services that are the subject of the complaint. 
 16.18     Sec. 20.  Minnesota Statutes 1998, section 62Q.105, 
 16.19  subdivision 3, is amended to read: 
 16.20     Subd. 3.  [APPEALS PROCESS.] Health plan companies shall 
 16.21  establish and make available to enrollees an impartial internal 
 16.22  appeals process according to section 62Q.108.  If a decision by 
 16.23  a health plan company regarding a complaint is partially or 
 16.24  wholly adverse to the complainant, the health plan company shall 
 16.25  advise the complainant of the right to appeal through 
 16.26  the impartial internal appeals process or to the 
 16.27  commissioner under section 62Q.106.  The health plan company 
 16.28  shall advise the complainant of the availability of an external 
 16.29  appeals process under section 62Q.109 and the conditions for 
 16.30  using the external appeals process. 
 16.31     Sec. 21.  Minnesota Statutes 1998, section 62Q.105, 
 16.32  subdivision 7, is amended to read: 
 16.33     Subd. 7.  [REPORTING.] Each health plan company shall 
 16.34  submit to the appropriate commissioner, as part of the company's 
 16.35  annual filing, data on the number and type of complaints that 
 16.36  are not resolved within 30 days.  A health plan company shall 
 17.1   also make this information available to the public upon 
 17.2   request.  A health plan company shall notify its continuous 
 17.3   quality improvement program under section 62Q.68 of all 
 17.4   complaints and appeals relating to quality of care.  
 17.5      Sec. 22.  Minnesota Statutes 1998, section 62Q.106, is 
 17.6   amended to read: 
 17.7      62Q.106 [DISPUTE RESOLUTION BY COMMISSIONER.] 
 17.8      (a) A complainant may at any time submit a complaint to the 
 17.9   appropriate commissioner to investigate.  After investigating a 
 17.10  complaint, or reviewing a company's decision, the appropriate 
 17.11  commissioner may order a remedy as authorized under this section 
 17.12  62Q.30 or chapter 45, 60A, or 62D.  
 17.13     (b) If the disputed issue relates to whether a service is 
 17.14  appropriate and necessary, the commissioner shall issue an order 
 17.15  only after consulting with appropriate experts knowledgeable, 
 17.16  trained, and practicing in the area in dispute, reviewing 
 17.17  pertinent literature, and considering the availability of 
 17.18  satisfactory alternatives.  
 17.19     (c) The commissioner shall take steps including but not 
 17.20  limited to fining, suspending, or revoking the license of a 
 17.21  health plan company that is the subject of repeated orders by 
 17.22  the commissioner that suggests a pattern of inappropriate 
 17.23  underutilization.  
 17.24     Sec. 23.  [62Q.108] [INTERNAL APPEALS PROCESS.] 
 17.25     Subdivision 1.  [RIGHT TO APPEAL.] An enrollee has the 
 17.26  right to appeal any of the following decisions according to 
 17.27  procedures under subdivisions 2 to 4: 
 17.28     (1) denial, reduction, or termination of a benefit or 
 17.29  failure to provide or make payment, in whole or in part, for a 
 17.30  benefit; 
 17.31     (2) failure to provide coverage of emergency services or 
 17.32  reimbursement of maintenance care or poststabilization care 
 17.33  under section 62Q.55; 
 17.34     (3) failure to provide a choice of providers under section 
 17.35  62Q.093; 
 17.36     (4) failure to provide qualified health care providers 
 18.1   under section 62Q.093; 
 18.2      (5) failure to provide access to specialty care under 
 18.3   section 62Q.52 or 62Q.59; 
 18.4      (6) failure to provide continuation of care under section 
 18.5   62Q.56; 
 18.6      (7) failure to provide coverage of routine patient costs in 
 18.7   connection with an approved clinical trial under section 62Q.60; 
 18.8      (8) failure to provide access to needed drugs under section 
 18.9   62Q.526; 
 18.10     (9) discrimination in delivery of services in violation of 
 18.11  section 62Q.125; 
 18.12     (10) the imposition of a limitation that is prohibited 
 18.13  under section 62J.725 and 
 18.14     (11) any other failure to comply with this chapter. 
 18.15     Subd. 2.  [PROCEDURE.] (a) A health plan company shall 
 18.16  establish and maintain an internal appeals process under which 
 18.17  an enrollee or provider, acting on behalf of an enrollee with 
 18.18  the enrollee's consent, may appeal a decision specified under 
 18.19  subdivision 1. 
 18.20     (b) The appeal may be communicated orally.  
 18.21     (c) The health plan company shall provide the complainant 
 18.22  with a written explanation of the appeals process. 
 18.23     (d) The internal appeals process shall include review by a 
 18.24  physician or other health care professional.  The health plan 
 18.25  company shall appoint one or more physicians or other health 
 18.26  care professionals who were not involved in making the decision 
 18.27  at issue in the appeal to review the decision. 
 18.28     (e) The health plan company must provide the enrollee and 
 18.29  the provider with a written determination upon conclusion of the 
 18.30  appeals process.  If the health plan company denies an appeal, 
 18.31  the health plan company shall provide in writing the reasons for 
 18.32  the denial and a notice of rights to any further appeal.  
 18.33     Subd. 3.  [RESPONSE TIME.] (a) Except as provided in 
 18.34  paragraph (b) and subdivision 4, a health plan company shall 
 18.35  conclude an appeal as soon as possible after receipt of the 
 18.36  appeal according to the medical exigencies of the case but in no 
 19.1   event later than 15 business days after the date of receipt of 
 19.2   the appeal. 
 19.3      (b) A health plan company may extend the deadline for a 
 19.4   nonexpedited appeal that does not involve a medical exigency for 
 19.5   an additional ten business days if the health plan company can 
 19.6   demonstrate to the appropriate commissioner that the cause for 
 19.7   the delay is beyond the control of the health plan company.  
 19.8   Before the original deadline under paragraph (a), a health plan 
 19.9   company must submit a written progress report and explanation 
 19.10  for the delay to the appropriate commissioner, the enrollee, and 
 19.11  the provider.  
 19.12     Subd. 4.  [EXPEDITED REVIEW PROCESS.] (a) A health plan 
 19.13  company shall establish procedures in writing for the expedited 
 19.14  consideration of appeals when the application of subdivision 3 
 19.15  could seriously jeopardize the life or health of the enrollee or 
 19.16  the enrollee's ability to regain maximum function. 
 19.17     (b) A request for an expedited appeal may be made orally or 
 19.18  in writing by an enrollee or provider who is otherwise entitled 
 19.19  to request the appeal. 
 19.20     (c) All necessary information for an expedited appeal, 
 19.21  including, but not limited to, the health plan company's 
 19.22  decision, shall be transmitted by telephone, facsimile, or other 
 19.23  similarly expeditious method. 
 19.24     (d) A health plan company must expedite an appeal if 
 19.25  requested by a physician who indicates that the life or health 
 19.26  of the enrollee or the enrollee's ability to regain maximum 
 19.27  function will be seriously jeopardized if the appeal is not 
 19.28  expedited. 
 19.29     Subd. 5.  [FURTHER APPEALS.] If the health plan company 
 19.30  fails to comply with any of the deadlines for completion of 
 19.31  appeals under this section or in the event that the health plan 
 19.32  company waives its rights to an internal review, the enrollee or 
 19.33  provider shall be relieved of any obligation to complete the 
 19.34  appeal and may proceed directly to seek further appeal through 
 19.35  any applicable external appeals process.  
 19.36     Subd. 6.  [BILLING SUSPENDED.] During an internal appeals 
 20.1   process, a health plan company shall suspend billings to the 
 20.2   enrollee, if applicable, for services that are the subject of 
 20.3   the appeal.  
 20.4      Sec. 24.  [62Q.109] [EXTERNAL APPEALS PROCESS.] 
 20.5      Subdivision 1.  [RIGHT TO EXTERNAL APPEAL.] A health plan 
 20.6   company shall provide for an external appeals process that meets 
 20.7   the requirements of this section.  An enrollee or provider, 
 20.8   acting on behalf of an enrollee with the enrollee's consent, may 
 20.9   request an external appeal of a decision appealable under 
 20.10  section 62Q.108 if the amount involved exceeds a significant 
 20.11  threshold, as determined by rule under subdivision 5, or the 
 20.12  patient's life or health is jeopardized as a consequence of the 
 20.13  decision.  An enrollee or provider may not request an external 
 20.14  appeal for denial of coverage for services that are specifically 
 20.15  listed in the health plan documents as excluded from coverage.  
 20.16     Subd. 2.  [EXHAUSTION OF INTERNAL APPEALS PROCESS.] A 
 20.17  health plan company may condition the use of the external 
 20.18  appeals process on completion of the internal appeals process 
 20.19  provided under section 62Q.108.  
 20.20     Subd. 3.  [CONTRACTING.] (a) An external appeal shall be 
 20.21  conducted under a contract, which is paid for by the health plan 
 20.22  company, between the commissioner of commerce and one or more 
 20.23  external appeal entities certified under section 62Q.1093. 
 20.24     (b) The contract shall be consistent with the rules adopted 
 20.25  under subdivision 5 and shall ensure that there is no real or 
 20.26  apparent conflict of interest in the conduct of external 
 20.27  appeals.  The contract shall provide that the direct costs of 
 20.28  the appeals process, not including costs of representation of 
 20.29  the enrollee, shall be paid by the health plan company. 
 20.30     Subd. 4.  [REQUIREMENTS.] (a) An external appeals process 
 20.31  shall ensure that the process for selecting a certified external 
 20.32  appeal entity does not create an incentive for an external 
 20.33  appeal entity to make a decision in a biased manner.  Rules 
 20.34  adopted under subdivision 5 shall provide for a procedure to 
 20.35  audit a sample of decisions by an external appeal entity. 
 20.36     (b) An external appeals process shall provide for a fair, 
 21.1   de novo determination.  The health plan company has the burden 
 21.2   of proof. 
 21.3      (c) A certified external appeal entity shall determine 
 21.4   whether a decision is an externally appealable decision, whether 
 21.5   the decision involves an expedited appeal, the appropriate 
 21.6   deadlines for an internal appeals process required due to 
 21.7   medical exigencies in a case, and whether an internal appeals 
 21.8   process has been completed. 
 21.9      (d) Each party to an externally appealable decision may 
 21.10  submit and review evidence related to the issues in dispute, use 
 21.11  the assistance or representation of one or more attorneys or 
 21.12  other individuals, and make an oral presentation. 
 21.13     (e) A health plan company involved in an external appeal 
 21.14  shall provide timely access to all records relating to the 
 21.15  matter of the externally appealable decision and to all 
 21.16  provisions of the health plan coverage, including, but not 
 21.17  limited to, any coverage manual, relating to the matter. 
 21.18     (f) A determination by an external appeal entity shall: 
 21.19     (1) be made orally or in writing, and if made orally, shall 
 21.20  be supplied to the parties in writing as soon as possible; 
 21.21     (2) be binding on the health plan company; 
 21.22     (3) be made according to medical exigencies of the case, 
 21.23  but in no event later than 60 days, or 72 hours in the case of 
 21.24  an expedited appeal, from the date of completion of filing of 
 21.25  the notice of external appeal; 
 21.26     (4) state, in layperson's language, the basis for the 
 21.27  determination, including, but not limited to, any basis in the 
 21.28  terms or conditions of the health plan, if relevant; and 
 21.29     (5) inform the enrollee of the enrollee's right to seek 
 21.30  further review by the courts. 
 21.31     Subd. 5.  [RULEMAKING.] The commissioners of commerce and 
 21.32  health shall adopt rules to ensure that an external appeals 
 21.33  process is conducted according to subdivisions 1 to 4. 
 21.34     Subd. 6.  [BILLINGS SUSPENDED.] During an external appeals 
 21.35  process, a health plan company shall suspend billings to the 
 21.36  enrollee, if applicable, for services that are the subject of 
 22.1   the appeal. 
 22.2      Sec. 25.  [62Q.1093] [EXTERNAL APPEAL ENTITY 
 22.3   CERTIFICATION.] 
 22.4      Subdivision 1.  [QUALIFICATIONS.] The commissioner of 
 22.5   commerce shall certify an external appeal entity if: 
 22.6      (1) there is no real or apparent conflict of interest that 
 22.7   would impede the entity conducting external appeals 
 22.8   independently of a health plan company; 
 22.9      (2) the entity conducts external appeals through clinical 
 22.10  peers; and 
 22.11     (3) the entity has sufficient medical, legal, and other 
 22.12  expertise and sufficient staffing to conduct external appeals on 
 22.13  a timely basis consistent with rules established under section 
 22.14  62Q.109, subdivision 5.  
 22.15     Subd. 2.  [RENEWAL; RULEMAKING.] The commissioner of 
 22.16  commerce shall adopt rules to renew the certification of an 
 22.17  external appeal entity.  The rules shall require that the 
 22.18  external appeal entity submit: 
 22.19     (1) the number of cases reviewed; 
 22.20     (2) a summary of the disposition of the cases; 
 22.21     (3) the length of time in making determinations on the 
 22.22  cases; and 
 22.23     (4) any other information required by the commissioner to 
 22.24  ensure the independence of the entity from the health plan 
 22.25  companies for which external appeals are being conducted. 
 22.26     Sec. 26.  [62Q.1095] [CONTINUING LEGAL RIGHTS.] 
 22.27     Nothing in sections 62Q.108 to 62Q.1093 shall be construed 
 22.28  as precluding any legal rights of enrollees or others under 
 22.29  state or federal law, including the right to file judicial 
 22.30  actions to enforce rights. 
 22.31     Sec. 27.  [62Q.125] [NONDISCRIMINATION IN DELIVERY OF 
 22.32  SERVICES.] 
 22.33     Subdivision 1.  [DELIVERY OF SERVICES.] Subject to 
 22.34  subdivision 2, a health plan company may not discriminate 
 22.35  against an enrollee in the delivery of health care services, 
 22.36  consistent with the benefits covered under a health plan or as 
 23.1   required by law, on the basis of race, color, ethnicity, 
 23.2   national origin, religion, sex, age, mental or physical 
 23.3   disability, sexual orientation, genetic information, or source 
 23.4   of payment. 
 23.5      Subd. 2.  [CONSTRUCTION.] Nothing in subdivision 1 shall be 
 23.6   construed as relating to eligibility to be covered, or offering 
 23.7   or guaranteeing the offer of coverage, under a health plan, the 
 23.8   application of any preexisting condition exclusion consistent 
 23.9   with applicable law, or premiums charged under the health plan.  
 23.10     Sec. 28.  Minnesota Statutes 1998, section 62Q.19, 
 23.11  subdivision 5a, is amended to read: 
 23.12     Subd. 5a.  [COOPERATION.] Each health plan company and 
 23.13  essential community provider shall cooperate to facilitate the 
 23.14  use of the essential community provider by the high risk and 
 23.15  special needs populations.  This includes cooperation on the 
 23.16  submission and processing of claims, sharing of all pertinent 
 23.17  records and data, including, but not limited to, performance 
 23.18  indicators and specific outcomes data, and the use of all 
 23.19  dispute resolution methods as defined in section 62Q.11, 
 23.20  subdivision 1 an external appeals process under section 62Q.109. 
 23.21     Sec. 29.  [62Q.523] [MINIMUM STAY FOR BREAST CANCER 
 23.22  TREATMENT.] 
 23.23     Subdivision 1.  [REQUIRED STAY.] (a) A health plan company 
 23.24  shall not: 
 23.25     (1) restrict benefits for a hospital length of stay in 
 23.26  connection with a mastectomy for the treatment of breast cancer 
 23.27  to less than 48 hours; 
 23.28     (2) restrict benefits for a hospital length of stay in 
 23.29  connection with a lymph node dissection for the treatment of 
 23.30  breast cancer to less than 24 hours; or 
 23.31     (3) require that a health care provider obtain 
 23.32  authorization from the health plan company for prescribing a 
 23.33  length of stay required under clause (1) or (2). 
 23.34     (b) Paragraph (a) shall not apply when the decision to 
 23.35  discharge the woman involved prior to the expiration of the 
 23.36  minimum length of stay otherwise required under paragraph (a) is 
 24.1   made by the attending provider in consultation with the woman or 
 24.2   in a case involving a partial mastectomy without lymph node 
 24.3   dissection. 
 24.4      Subd. 2.  [PROHIBITIONS.] A health plan company shall not: 
 24.5      (1) deny a woman eligibility, or continued eligibility, to 
 24.6   enroll or to renew coverage under the terms of a health plan, 
 24.7   solely for the purpose of avoiding the requirements of this 
 24.8   section; 
 24.9      (2) provide monetary payments or rebates to a woman to 
 24.10  encourage the woman to accept less than the minimum protections 
 24.11  available under this section; 
 24.12     (3) penalize or otherwise reduce or limit the reimbursement 
 24.13  of an attending provider because the provider provided care to 
 24.14  an enrollee according to this section; 
 24.15     (4) provide incentives, monetary or otherwise, to an 
 24.16  attending provider to induce the provider to provide care to an 
 24.17  enrollee in a manner inconsistent with this section; or 
 24.18     (5) subject to subdivision 3, restrict benefits for any 
 24.19  portion of a period within a hospital length of stay required 
 24.20  under subdivision 1 in a manner that is less favorable than the 
 24.21  benefits provided for any preceding portion of the stay. 
 24.22     Subd. 3.  [CONSTRUCTION.] (a) Nothing in this section shall 
 24.23  be construed to require a woman who is an enrollee: 
 24.24     (1) to undergo a mastectomy or lymph node dissection in a 
 24.25  hospital; or 
 24.26     (2) to stay in the hospital for a fixed period of time 
 24.27  following a mastectomy or lymph node dissection. 
 24.28     (b) This section shall not apply to a health plan that does 
 24.29  not provide benefits for hospital lengths of stay in connection 
 24.30  with a mastectomy or lymph node dissection for the treatment of 
 24.31  breast cancer. 
 24.32     (c) Nothing in this section shall be construed as 
 24.33  preventing a health plan company from imposing deductibles, 
 24.34  coinsurance, or other cost sharing for benefits for hospital 
 24.35  lengths of stay in connection with a mastectomy or lymph node 
 24.36  dissection for the treatment of breast cancer under the health 
 25.1   plan, except that the coinsurance or other cost sharing for any 
 25.2   portion of a period within a hospital length of stay required 
 25.3   under subdivision 1 may not be greater than the coinsurance or 
 25.4   cost sharing for any preceding portion of such stay. 
 25.5      (d) Nothing in this section shall be construed to prevent a 
 25.6   health plan company from negotiating the level and type of 
 25.7   reimbursement with a provider for care provided in accordance 
 25.8   with this section. 
 25.9      Sec. 30.  [62Q.524] [BENEFITS FOR RECONSTRUCTIVE BREAST 
 25.10  SURGERY.] 
 25.11     Subdivision 1.  [REQUIREMENT.] (a) Notwithstanding section 
 25.12  62A.25, a health plan company that provides coverage for breast 
 25.13  surgery in connection with a mastectomy shall provide coverage 
 25.14  for reconstructive breast surgery resulting from the mastectomy 
 25.15  according to this section.  The health plan shall include 
 25.16  coverage for all stages of reconstructive breast surgery 
 25.17  performed on a nondiseased breast to establish symmetry with the 
 25.18  diseased breast when reconstruction on the diseased breast is 
 25.19  performed and coverage for prostheses and complications of 
 25.20  mastectomy, including, but not limited to, lymphedema. 
 25.21     (b) The term "reconstructive breast surgery" means surgery 
 25.22  performed as a result of a mastectomy to reestablish symmetry 
 25.23  between two breasts, and includes augmentation mammaplasty, 
 25.24  reduction mammaplasty, and mastopexy. 
 25.25     Subd. 2.  [PROHIBITIONS.] (a) A health plan company may not 
 25.26  deny coverage described in subdivision 1 on the basis that the 
 25.27  coverage is for cosmetic surgery. 
 25.28     (b) A health plan company shall not: 
 25.29     (1) deny a woman eligibility, or continued eligibility, to 
 25.30  enroll or to renew coverage under the terms of a health plan, 
 25.31  solely for the purpose of avoiding the requirements of this 
 25.32  section; 
 25.33     (2) provide monetary payments or rebates to a woman to 
 25.34  encourage the woman to accept less than the minimum protections 
 25.35  available under this section; 
 25.36     (3) penalize or otherwise reduce or limit the reimbursement 
 26.1   of an attending provider because the provider provided care to 
 26.2   an enrollee according to this section; 
 26.3      (4) provide incentives, monetary or otherwise, to an 
 26.4   attending provider to induce the provider to provide care to an 
 26.5   enrollee in a manner inconsistent with this section; or 
 26.6      (5) subject to subdivision 3, restrict benefits for 
 26.7   coverage required under subdivision 1 in a manner that is less 
 26.8   favorable than the benefits provided for coverage for other 
 26.9   breast surgery in connection with a mastectomy. 
 26.10     Subd. 3.  [CONSTRUCTION.] (a) Nothing in this section shall 
 26.11  be construed to require a woman who is an enrollee to undergo 
 26.12  reconstructive breast surgery. 
 26.13     (b) This section shall not apply to a health plan that does 
 26.14  not provide benefits for mastectomies. 
 26.15     (c) Nothing in this section shall be construed as 
 26.16  preventing a health plan company from imposing deductibles, 
 26.17  coinsurance, or other cost sharing for benefits for 
 26.18  reconstructive breast surgery under the health plan, except that 
 26.19  the coinsurance or other cost sharing for any portion may not be 
 26.20  greater than the coinsurance or cost sharing that is otherwise 
 26.21  applicable to benefits for mastectomies. 
 26.22     (d) Nothing in this section shall be construed to prevent a 
 26.23  health plan company from negotiating the level and type of 
 26.24  reimbursement with a provider for care provided according to 
 26.25  this section. 
 26.26     Sec. 31.  [62Q.526] [ACCESS TO PRESCRIPTION DRUGS.] 
 26.27     Subdivision 1.  [COVERAGE OF INVESTIGATIONAL USES.] A 
 26.28  health plan company that provides coverage of prescription drugs 
 26.29  or medical devices shall not deny coverage of a prescription 
 26.30  drug or medical device on the basis that the use is 
 26.31  investigational, if the use is included in the labeling 
 26.32  authorized under federal law regardless of any postmarketing 
 26.33  requirements imposed by federal law. 
 26.34     Subd. 2.  [FORMULARY REQUIREMENTS.] If a health plan 
 26.35  company provides benefits with respect to prescription drugs, 
 26.36  but the coverage limits benefits to drugs included in a 
 27.1   formulary, the health plan company shall: 
 27.2      (1) ensure participation of participating physicians and 
 27.3   pharmacists in the development of the formulary; 
 27.4      (2) disclose to providers and, upon request, to enrollees 
 27.5   the nature of the formulary restrictions; and 
 27.6      (3) provide for exceptions from the formulary limitation 
 27.7   when a nonformulary alternative is medically indicated by the 
 27.8   prescribing health care professional. 
 27.9      Subd. 3.  [CONSTRUCTION.] Nothing in this section shall be 
 27.10  construed as requiring a health plan company to provide coverage 
 27.11  of prescription drugs or medical devices.  
 27.12     Sec. 32.  Minnesota Statutes 1998, section 62Q.55, is 
 27.13  amended to read: 
 27.14     62Q.55 [EMERGENCY SERVICES.] 
 27.15     Subdivision 1.  [COVERAGE OF EMERGENCY SERVICES.] (a) 
 27.16  Enrollees have the right to available and accessible emergency 
 27.17  services, 24 hours a day and seven days a week.  The health plan 
 27.18  company shall inform its enrollees how to obtain emergency 
 27.19  care and, if. 
 27.20     (b) The health plan shall cover emergency services without 
 27.21  the need for prior authorization for emergency services is 
 27.22  required, shall make available a toll-free number, which is 
 27.23  answered 24 hours a day, to answer questions about emergency 
 27.24  services and to receive reports and provide authorizations, 
 27.25  where appropriate, for treatment of emergency medical 
 27.26  conditions.  Emergency services shall be covered whether 
 27.27  provided by participating or nonparticipating providers and 
 27.28  whether provided within or outside the health plan company's 
 27.29  service area.  In reviewing a denial for coverage of emergency 
 27.30  services, the health plan company shall take the following 
 27.31  factors into consideration: 
 27.32     (1) a reasonable layperson's belief that the circumstances 
 27.33  required immediate medical care that could not wait until the 
 27.34  next working day or next available clinic appointment; 
 27.35     (2) the time of day and day of the week the care was 
 27.36  provided; 
 28.1      (3) the presenting symptoms, including, but not limited to, 
 28.2   severe pain, to ensure that the decision to reimburse the 
 28.3   emergency care is not made solely on the basis of the actual 
 28.4   diagnosis; 
 28.5      (4) the enrollee's efforts to follow the health plan 
 28.6   company's established procedures for obtaining emergency care; 
 28.7   and 
 28.8      (5) any circumstances that precluded use of the health plan 
 28.9   company's established procedures for obtaining emergency care. 
 28.10     (b) The health plan company may require enrollees to notify 
 28.11  the health plan company of nonreferred emergency care as soon as 
 28.12  possible, but not later than 48 hours, after the emergency care 
 28.13  is initially provided.  However, emergency care which would have 
 28.14  been covered under the contract had notice been provided within 
 28.15  the set time frame must be covered. 
 28.16     (c) Notwithstanding paragraphs (a) and (b), a health plan 
 28.17  company, health insurer, or health coverage plan that is in 
 28.18  compliance with the rules regarding accessibility of services 
 28.19  adopted under section 62D.20 is in compliance with this section. 
 28.20     (c) Under no circumstances shall coverage for emergency 
 28.21  care be denied when an enrollee chooses the nearest emergency 
 28.22  care facility. 
 28.23     (d) The health plan company shall cover emergency services 
 28.24  according to this section without regard to any other term or 
 28.25  condition of coverage other than: 
 28.26     (1) applicable cost-sharing; or 
 28.27     (2) exclusion or coordination of benefits or an affiliation 
 28.28  or waiting period permitted under section 2701 of the Public 
 28.29  Health Service Act, section 701 of the Employee Retirement 
 28.30  Income Security Act of 1974, or section 9801 of the Internal 
 28.31  Revenue Code of 1986. 
 28.32     Subd. 2.  [COVERAGE FOR SERVICES PROVIDED BY 
 28.33  NONPARTICIPATING PROVIDER.] If emergency services are provided 
 28.34  to an enrollee by a nonparticipating provider, the enrollee is 
 28.35  not liable for amounts that exceed the amounts of liability that 
 28.36  would be incurred if the services were provided by a 
 29.1   participating health care provider.  The health plan company 
 29.2   shall pay an amount that is not less than the amount paid to a 
 29.3   participating health care provider for the same services. 
 29.4      Subd. 3.  [REIMBURSEMENT FOR MAINTENANCE CARE AND 
 29.5   POSTSTABILIZATION CARE.] In the case of services other than 
 29.6   emergency services for which coverage is available under a 
 29.7   health plan, the health plan company shall provide for 
 29.8   reimbursement for services provided to an enrollee by a 
 29.9   nonparticipating provider in conjunction with emergency services 
 29.10  if the services are maintenance care or poststabilization care 
 29.11  that promote efficient and timely coordination of care after an 
 29.12  enrollee has been determined to be stable. 
 29.13     Subd. 4.  [DEFINITIONS.] (a) For purposes of this section, 
 29.14  the terms defined in this subdivision have the meanings given. 
 29.15     (b) "Emergency medical condition" means a medical condition 
 29.16  manifesting itself by acute symptoms of sufficient severity, 
 29.17  including, but not limited to, severe pain, such that a prudent 
 29.18  layperson who possesses an average knowledge of health and 
 29.19  medicine could reasonably expect the absence of immediate 
 29.20  medical attention to result in serious impairment of a bodily 
 29.21  function, serious dysfunction of a bodily organ, or placing the 
 29.22  individual's health, or the health of an unborn child, in 
 29.23  serious jeopardy. 
 29.24     (c) "Emergency services" means: 
 29.25     (1) a medical screen examination that is within the 
 29.26  capability of the emergency department of a hospital, including, 
 29.27  but not limited to, ancillary services routinely available to 
 29.28  the emergency department, to evaluate an emergency medical 
 29.29  condition; and 
 29.30     (2) within the capability of the staff and facilities 
 29.31  available at the hospital, any other medical examination and 
 29.32  treatment required to stabilize the patient. 
 29.33     Sec. 33.  Minnesota Statutes 1998, section 62Q.56, 
 29.34  subdivision 1, is amended to read: 
 29.35     Subdivision 1.  [CHANGE IN HEALTH CARE PROVIDER; WRITTEN 
 29.36  PLAN.] (a) If enrollees are required to access services through 
 30.1   selected primary care providers for coverage, the health plan 
 30.2   company shall prepare a written plan that provides for 
 30.3   continuity of care in the event of any contract termination 
 30.4   between the health plan company and any of the 
 30.5   contracted resulting in termination of coverage for the services 
 30.6   of a primary care providers provider or general hospital 
 30.7   providers provider.  The written plan must explain: 
 30.8      (1) how the health plan company will inform affected 
 30.9   enrollees, insureds, or beneficiaries about termination at least 
 30.10  30 days before the termination is effective, if the health plan 
 30.11  company or health care network cooperative has received at least 
 30.12  120 days' prior notice; 
 30.13     (2) how the health plan company will inform the affected 
 30.14  enrollees about what other participating providers are available 
 30.15  to assume care and how it will facilitate an orderly transfer of 
 30.16  its enrollees from the terminating terminated provider to the 
 30.17  new provider to maintain continuity of care; 
 30.18     (3) the procedures by which enrollees will be transferred 
 30.19  to other participating providers, when special medical needs, 
 30.20  special risks, or other special circumstances, such as cultural 
 30.21  or language barriers, require them to have a longer transition 
 30.22  period or be transferred to nonparticipating providers; 
 30.23     (4) who will identify enrollees with special medical needs 
 30.24  or at special risk and what criteria will be used for this 
 30.25  determination; and 
 30.26     (5) how continuity of care will be provided for enrollees 
 30.27  identified as having special needs or at special risk, and 
 30.28  whether the health plan company has assigned this responsibility 
 30.29  to its contracted primary care providers. 
 30.30     (b) If the contract termination was not for cause, 
 30.31  enrollees can request a referral to the terminating terminated 
 30.32  provider for up to 120 days if they have special medical needs 
 30.33  or have other special circumstances, such as cultural or 
 30.34  language barriers.  The health plan company can require medical 
 30.35  records and other supporting documentation in support of the 
 30.36  requested referral.  Each request for referral to a terminating 
 31.1   terminated provider shall be considered by the health plan 
 31.2   company on a case-by-case basis. 
 31.3      (c) If the contract termination was for cause, enrollees 
 31.4   must be notified of the change and transferred to participating 
 31.5   providers in a timely manner so that health care services remain 
 31.6   available and accessible to the affected enrollees.  The health 
 31.7   plan company is not required to refer an enrollee back to the 
 31.8   terminating terminated provider if the termination was for cause.
 31.9      Sec. 34.  Minnesota Statutes 1998, section 62Q.56, is 
 31.10  amended by adding a subdivision to read: 
 31.11     Subd. 1a.  [ONGOING TREATMENT; TRANSITION PERIOD.] (a) In 
 31.12  the event of any contract termination resulting in termination 
 31.13  of coverage for the services of a primary care provider or 
 31.14  general hospital provider, a health plan company shall provide 
 31.15  coverage to permit an enrollee who is undergoing a course of 
 31.16  treatment from the terminated provider at the time of the notice 
 31.17  described in subdivision 1, paragraph (a), clause (1), to 
 31.18  continue the course of treatment with the provider for at least 
 31.19  90 days from the date of the notice except as provided in 
 31.20  paragraphs (b) to (d). 
 31.21     (b) The transitional period under this subdivision for 
 31.22  institutional or inpatient care from a terminated provider shall 
 31.23  extend until the discharge or termination of the period of 
 31.24  institutionalization and shall include institutional care 
 31.25  provided within a reasonable time of the date of termination of 
 31.26  provider status if the care was scheduled before the date of the 
 31.27  notice described in subdivision 1, paragraph (a), clause (1), or 
 31.28  if the enrollee on that date was on an established waiting list 
 31.29  or otherwise scheduled to have the care. 
 31.30     (c) If an enrollee has entered the second trimester of 
 31.31  pregnancy at the time of the notice described in subdivision 1, 
 31.32  paragraph (a), clause (1), and the terminated provider was 
 31.33  treating the pregnancy before that date, the transitional period 
 31.34  under this subdivision with respect to the provider's treatment 
 31.35  of the pregnancy shall extend through the provision of 
 31.36  postpartum care directly related to the delivery.  
 32.1      (d) If an enrollee was determined to be terminally ill at 
 32.2   the time of the notice described in subdivision 1, paragraph 
 32.3   (a), clause (1), and the terminated provider was treating the 
 32.4   terminal illness before that date, the transitional period under 
 32.5   this subdivision shall extend for the remainder of the 
 32.6   individual's life for care directly related to the treatment of 
 32.7   the terminal illness. 
 32.8      (e) A health plan company may condition coverage of 
 32.9   continued treatment under this subdivision upon the terminated 
 32.10  provider agreeing to: 
 32.11     (1) accept reimbursement from the health plan company at 
 32.12  the rates applicable prior to the start of the transition period 
 32.13  as payment in full and not impose cost-sharing with respect to 
 32.14  the enrollee in an amount that would exceed the cost-sharing 
 32.15  that could have been imposed if the contract had not been 
 32.16  terminated; 
 32.17     (2) adhere to the quality assurance standards of the health 
 32.18  plan company responsible for payment and to provide the health 
 32.19  plan company with necessary medical information related to the 
 32.20  care provided; and 
 32.21     (3) otherwise adhere to the health plan company's policies 
 32.22  and procedures, including procedures regarding referrals, prior 
 32.23  authorization, and providing services under a treatment plan 
 32.24  approved by the health plan company.  
 32.25     Sec. 35.  Minnesota Statutes 1998, section 62Q.56, is 
 32.26  amended by adding a subdivision to read: 
 32.27     Subd. 4.  [CONTRACT TERMINATION DEFINED.] For purposes of 
 32.28  this section, "contract termination" includes the expiration or 
 32.29  nonrenewal of a contract.  "Contract termination" does not 
 32.30  include termination of a contract for failure to meet applicable 
 32.31  quality standards or for fraud.  
 32.32     Sec. 36.  Minnesota Statutes 1998, section 62Q.56, is 
 32.33  amended by adding a subdivision to read: 
 32.34     Subd. 5.  [CONSTRUCTION.] Nothing in this section shall be 
 32.35  construed to require the coverage of benefits that would not 
 32.36  have been covered if the terminated provider involved remained a 
 33.1   participating provider. 
 33.2      Sec. 37.  [62Q.59] [ACCESS TO SPECIALTY CARE.] 
 33.3      Subdivision 1.  [SPECIALTY CARE FOR COVERED SERVICES.] (a) 
 33.4   If an enrollee has a condition or disease of sufficient 
 33.5   seriousness and complexity to require treatment by a specialist, 
 33.6   and benefits for such treatment are provided under the health 
 33.7   plan, the health plan company shall make or provide for a 
 33.8   referral to a specialist to provide the treatment for the 
 33.9   condition or disease. 
 33.10     (b) A health plan company may require that the care 
 33.11  provided to an individual pursuant to a referral under paragraph 
 33.12  (a) be: 
 33.13     (1) pursuant to a treatment plan, if the treatment plan is 
 33.14  developed by the specialist in consultation with the designated 
 33.15  primary care provider and the individual or the individual's 
 33.16  designee; and 
 33.17     (2) in accordance with applicable quality assurance and 
 33.18  utilization review standards of the health plan company. 
 33.19     Nothing in this paragraph shall be construed as preventing 
 33.20  a treatment plan for an individual from requiring a specialist 
 33.21  to provide the primary care provider with regular updates on the 
 33.22  specialty care provided, as well as all necessary medical 
 33.23  information.  
 33.24     (c) A health plan company is not required under paragraph 
 33.25  (a) to provide for a referral to a specialist who is not a 
 33.26  participating provider, unless the health plan does not have a 
 33.27  specialist acceptable to the enrollee who is available and 
 33.28  accessible to treat the individual's condition and that is a 
 33.29  participating provider with respect to such treatment. 
 33.30     (d) If a health plan company refers an individual to a 
 33.31  nonparticipating specialist under paragraph (a), services 
 33.32  provided according to the approved treatment plan, if any, shall 
 33.33  be provided at no additional cost to the individual beyond what 
 33.34  the individual would otherwise pay for services received by a 
 33.35  specialist that is a participating provider. 
 33.36     Subd. 2.  [SPECIALISTS AS PRIMARY CARE PROVIDERS.] (a) A 
 34.1   health plan company shall have a procedure by which an 
 34.2   individual who is an enrollee and who has an ongoing special 
 34.3   condition may receive a referral to a specialist for the 
 34.4   condition who shall be responsible for and capable of providing 
 34.5   and coordinating the individual's primary and specialty care.  
 34.6   If an individual's care would most appropriately be coordinated 
 34.7   by a specialist, the health plan company shall refer the 
 34.8   individual to a specialist. 
 34.9      (b) A specialist for whom a referral is acquired under 
 34.10  paragraph (a) shall be permitted to treat the individual without 
 34.11  a referral from the individual's primary care provider and may 
 34.12  authorize referrals, procedures, tests, and other medical 
 34.13  services as the individual's primary care provider would 
 34.14  otherwise be permitted to provide or authorize, subject to the 
 34.15  terms of any treatment plan under subdivision 1, paragraph (b). 
 34.16     (c) "Ongoing special condition" means a condition or 
 34.17  disease that: 
 34.18     (1) is life-threatening, degenerative, or disabling; and 
 34.19     (2) requires specialized medical care over a prolonged 
 34.20  period of time. 
 34.21     (d) The provisions of subdivision 1, paragraphs (b) to (d), 
 34.22  apply to referrals under this subdivision.  
 34.23     Subd. 3.  [STANDING REFERRALS.] (a) A health plan company 
 34.24  shall have a procedure by which an individual who is an enrollee 
 34.25  and who has a condition that requires ongoing care from a 
 34.26  specialist may receive a standing referral to a specialist for 
 34.27  treatment of the condition.  If the health plan company, or if 
 34.28  the primary care provider in consultation with the medical 
 34.29  director of the health plan company and the specialist, if any, 
 34.30  determines that a standing referral is appropriate, the health 
 34.31  plan company shall make a referral to a specialist.  
 34.32     (b) The provisions of subdivision 1, paragraphs (b) to (d), 
 34.33  apply to referrals under this subdivision.  
 34.34     Sec. 38.  [62Q.60] [COVERAGE FOR APPROVED CLINICAL TRIALS.] 
 34.35     Subdivision 1.  [DEFINITIONS.] (a) For purposes of this 
 34.36  section, the terms defined in this subdivision have the meanings 
 35.1   given. 
 35.2      (b) "Approved clinical trial" means a clinical research 
 35.3   study or clinical investigation approved and funded by one or 
 35.4   more of the following: 
 35.5      (1) the National Institute of Health; 
 35.6      (2) a cooperative group or center of the National Institute 
 35.7   of Health; 
 35.8      (3) the United States Department of Veterans Affairs; or 
 35.9      (4) the United States Department of Defense. 
 35.10     (c) "Qualified enrollee" means an enrollee: 
 35.11     (1) who has a life-threatening or serious illness for which 
 35.12  no standard treatment is effective; 
 35.13     (2) who is eligible to participate in an approved clinical 
 35.14  trial according to the trial protocol with respect to treatment 
 35.15  of the illness; and 
 35.16     (3) whose participation in the approved clinical trial 
 35.17  offers meaningful potential for significant clinical benefit for 
 35.18  the enrollee. 
 35.19     (d) "Routine patient costs" do not include the cost of 
 35.20  tests or measurements conducted primarily for the purpose of the 
 35.21  approved clinical trial involved. 
 35.22     Subd. 2.  [COVERAGE REQUIRED.] (a) A health plan company 
 35.23  that provides coverage to a qualified enrollee may not deny the 
 35.24  enrollee participation in an approved clinical trial if the 
 35.25  enrollee's referring physician is a participating provider and 
 35.26  has concluded that the enrollee's participation in the trial 
 35.27  would be appropriate or if the enrollee provides medical and 
 35.28  scientific information establishing that the enrollee's 
 35.29  participation in the trial would be appropriate.  The health 
 35.30  plan company may not deny, limit, or impose additional 
 35.31  conditions on the coverage of routine patient costs for items 
 35.32  and services furnished in connection with participation in the 
 35.33  approved clinical trial.  The health plan company may not 
 35.34  discriminate against the enrollee on the basis of the enrollee's 
 35.35  participation in the approved clinical trial. 
 35.36     (b) If one or more participating providers is participating 
 36.1   in the approved clinical trial, nothing in paragraph (a) shall 
 36.2   be construed as preventing a health plan company from requiring 
 36.3   that a qualified enrollee participate in the approved clinical 
 36.4   trial through the participating provider if the provider accepts 
 36.5   the individual as a participant in the trial. 
 36.6      Subd. 3.  [PAYMENT.] (a) A health plan company shall 
 36.7   provide for payment of routine patient costs but is not required 
 36.8   to pay for costs of items and services that are reasonably 
 36.9   expected to be paid by the sponsors of the approved clinical 
 36.10  trial, as determined by the appropriate commissioner. 
 36.11     (b) If the covered item or service is provided by a 
 36.12  participating provider, the payment rate shall be at the agreed 
 36.13  upon rate.  If the covered item or service is provided by a 
 36.14  nonparticipating provider, the payment rate shall be at the rate 
 36.15  the health plan company would normally pay for comparable items 
 36.16  or services provided by a participating provider. 
 36.17     Subd. 4.  [CONSTRUCTION.] Nothing in this section shall be 
 36.18  construed to limit a health plan company's coverage with respect 
 36.19  to clinical trials.  
 36.20     Sec. 39.  [62Q.68] [QUALITY ASSURANCE PROGRAM.] 
 36.21     Subdivision 1.  [PROGRAM REQUIRED.] A health plan company 
 36.22  shall establish and maintain an ongoing internal quality 
 36.23  assurance and continuous quality improvement program that meets 
 36.24  the requirements of subdivision 2. 
 36.25     Subd. 2.  [PROGRAM ELEMENTS.] A quality assurance and 
 36.26  continuous quality improvement program must: 
 36.27     (1) be administered by a separate identifiable unit within 
 36.28  the health plan company; 
 36.29     (2) have an annually updated written plan that specifies: 
 36.30     (i) the activities to be conducted; 
 36.31     (ii) the organizational structure; and 
 36.32     (iii) the criteria and procedures for the assessment of 
 36.33  quality; 
 36.34     (3) provide for systematic review of the type of health 
 36.35  services provided, the consistency of services provided, and 
 36.36  patient outcomes; 
 37.1      (4) use criteria that are based on performance and patient 
 37.2   outcomes.  Under no circumstances shall criteria be used that 
 37.3   limit or deny care and treatment based on age, frailty, physical 
 37.4   or mental capacity, or any other human condition; 
 37.5      (5) include criteria that are directed specifically at 
 37.6   meeting the needs of at-risk populations and covered individuals 
 37.7   with chronic conditions or severe illnesses, including, but not 
 37.8   limited to, gender-specific criteria and pediatric-specific 
 37.9   criteria; 
 37.10     (6) include methods for informing covered individuals of 
 37.11  the benefit of preventive care and what specific benefits with 
 37.12  respect to preventive care are covered under the health plan; 
 37.13     (7) make available to the public a description of the 
 37.14  criteria used under clause (4); 
 37.15     (8) have procedures for reporting possible quality concerns 
 37.16  by providers and enrollees and for remedial actions to correct 
 37.17  quality problems, including, but not limited to, written 
 37.18  procedures for responding to concerns and taking appropriate 
 37.19  corrective action; 
 37.20     (9) provide for an analysis, using data that includes data 
 37.21  collected under section 62J.451, subdivision 6a, of the health 
 37.22  plan company's performance on quality measures; and 
 37.23     (10) provide for a drug utilization review program 
 37.24  according to section 62Q.69. 
 37.25     Subd. 3.  [VARIANCES.] The appropriate commissioner may 
 37.26  provide by rule for variations in the application of this 
 37.27  section to health plan companies based on differences in the 
 37.28  delivery system among the health plan companies as the 
 37.29  commissioner deems appropriate.  
 37.30     Sec. 40.  [62Q.69] [DRUG UTILIZATION PROGRAM.] 
 37.31     A health plan company that offers a health plan providing 
 37.32  benefits for prescription drugs shall establish and maintain, as 
 37.33  part of its internal quality assurance and continuous quality 
 37.34  improvement program under section 62Q.68, a drug utilization 
 37.35  program that: 
 37.36     (1) encourages appropriate use of prescription drugs by 
 38.1   enrollees and providers; and 
 38.2      (2) takes action to reduce the incidence of improper drug 
 38.3   use and adverse drug reactions and interaction. 
 38.4      Sec. 41.  [62Q.70] [DISCLOSURE REQUIREMENTS.] 
 38.5      Subdivision 1.  [DISCLOSURE REQUIRED.] (a) A health plan 
 38.6   company shall provide in writing the information specified under 
 38.7   subdivision 2 to an enrollee at the time of initial coverage 
 38.8   under a health plan and at least annually thereafter. 
 38.9      (b) A health plan company shall provide in writing notice 
 38.10  of any significant changes in the information specified under 
 38.11  subdivision 2 to an enrollee within 14 days before or after the 
 38.12  date of the change. 
 38.13     (c) Upon request, a health plan company shall provide in 
 38.14  writing the information specified under subdivision 2 or 3 to an 
 38.15  enrollee, the appropriate commissioner, or a prospective 
 38.16  enrollee. 
 38.17     Subd. 2.  [DISCLOSURE INFORMATION.] A health plan company 
 38.18  shall disclose: 
 38.19     (1) the service area of the health plan; 
 38.20     (2) the benefits offered under the health plan, including: 
 38.21     (i) covered benefits, benefit limits, and coverage 
 38.22  exclusions; 
 38.23     (ii) cost sharing, deductibles, coinsurance, and copayment 
 38.24  amounts, any liability for balance billing, any maximum 
 38.25  limitations on out-of-pocket expenses, and the maximum 
 38.26  out-of-pocket costs for services that are provided by 
 38.27  nonparticipating providers or that are furnished without meeting 
 38.28  the applicable utilization review requirements; 
 38.29     (iii) the extent to which benefits may be obtained from 
 38.30  nonparticipating providers; 
 38.31     (iv) the extent to which an enrollee may select from among 
 38.32  participating providers and the types of providers participating 
 38.33  in the health plan; 
 38.34     (v) the process for determining experimental coverage; and 
 38.35     (vi) the use of a prescription drug formulary; 
 38.36     (3) a description of: 
 39.1      (i) the number, mix, and distribution of providers under 
 39.2   the health plan; 
 39.3      (ii) out-of-network coverage, if any; 
 39.4      (iii) any point-of-service option and any supplemental 
 39.5   premium or cost-sharing for the option; 
 39.6      (iv) the procedures for an enrollee to select, access, and 
 39.7   change participating primary and specialty care providers; 
 39.8      (v) the rights and procedures for obtaining referrals, 
 39.9   including, but not limited to, standing referrals, to 
 39.10  participating and nonparticipating providers; 
 39.11     (vi) the name, address, and telephone number of 
 39.12  participating health care providers and an indication of whether 
 39.13  each provider is available to accept new patients; 
 39.14     (vii) any limitations imposed on the selection of 
 39.15  qualifying participating health care providers, including any 
 39.16  limitations imposed under section 62Q.093, subdivision 2, 
 39.17  paragraph (b); and 
 39.18     (viii) how the health plan company addresses the needs of 
 39.19  enrollees who do not speak English or who have other special 
 39.20  communication needs in accessing providers under the health 
 39.21  plan, including, but not limited to, the provision of the 
 39.22  information described in this subdivision and subdivision 3 in a 
 39.23  language other than English if five percent of the health plan's 
 39.24  enrollees communicate in that language; 
 39.25     (4) out-of-area coverage provided by the health plan; 
 39.26     (5) coverage of emergency services, including: 
 39.27     (i) the appropriate use of emergency services, use of the 
 39.28  911 telephone system or its local equivalent in emergency 
 39.29  situations, and an explanation of what constitutes an emergency 
 39.30  situation; 
 39.31     (ii) the process and procedures of the health plan company 
 39.32  for obtaining emergency services; and 
 39.33     (iii) the location of emergency departments and other 
 39.34  settings in which health plan physicians and hospitals provide 
 39.35  emergency services and poststabilization care; 
 39.36     (6) in the case of health insurance coverage, a description 
 40.1   of the overall loss-ratio for the coverage; 
 40.2      (7) rules regarding prior authorization or other review 
 40.3   requirements that could result in noncoverage or nonpayment; 
 40.4      (8) all appeal or complaint rights and procedures under the 
 40.5   health plan, including the method for filing complaints and the 
 40.6   time frames and circumstances for acting on complaints and 
 40.7   appeals, who is the applicable authority with respect to the 
 40.8   health plan, and the availability of assistance through the 
 40.9   office of health care consumer assistance, advocacy, and 
 40.10  information to enrollees; 
 40.11     (9) a summary description of the data on quality collected 
 40.12  under section 62J.451, subdivision 6a, including a summary 
 40.13  description of the data on satisfaction of enrollees, voluntary 
 40.14  disenrollment, and complaints and appeals; 
 40.15     (10) a summary of provider reimbursement methodologies as 
 40.16  provided under section 62J.72, subdivision 1; 
 40.17     (11) the mailing addresses and telephone numbers to be used 
 40.18  by enrollees seeking information or authorization for treatment; 
 40.19  and 
 40.20     (12) notice that the information described in subdivision 3 
 40.21  is available upon request.  
 40.22     Subd. 3.  [INFORMATION MADE AVAILABLE UPON REQUEST.] Upon 
 40.23  request, a health plan company shall disclose: 
 40.24     (1) a description of procedures used and requirements of a 
 40.25  utilization review program under chapter 62M; 
 40.26     (2) information on the number of complaints and appeals and 
 40.27  the disposition in the aggregate of the complaints and appeals; 
 40.28     (3) a description of the credentials of each participating 
 40.29  provider; 
 40.30     (4) a description of the policies and procedures 
 40.31  established to comply with section 62Q.71 regarding patient 
 40.32  confidentiality; and 
 40.33     (5) a description of the nature of any drug formulary 
 40.34  restrictions. 
 40.35     Subd. 4.  [UNIFORM REPORTING STANDARDS; RULES.] The 
 40.36  commissioners of health and commerce shall jointly adopt rules 
 41.1   establishing uniform reporting standards for the information 
 41.2   required to be disclosed under this section.  The rules shall 
 41.3   enable prospective enrollees to compare attributes of different 
 41.4   health plans offered within an area. 
 41.5      Subd. 5.  [CONSTRUCTION.] Nothing in this section shall be 
 41.6   construed to require public disclosure of individual contracts 
 41.7   or financial arrangements between a health plan company and a 
 41.8   provider. 
 41.9      Sec. 42.  [62Q.71] [PROTECTION OF PATIENT CONFIDENTIALITY.] 
 41.10     If a health plan company maintains medical records or other 
 41.11  health information regarding enrollees, the health plan company 
 41.12  shall establish procedures to: 
 41.13     (1) safeguard the privacy of any individually identifiable 
 41.14  enrollee information; 
 41.15     (2) maintain medical records and other health information 
 41.16  in a manner that is accurate and timely; and 
 41.17     (3) ensure timely access by an enrollee to the enrollee's 
 41.18  medical record and other health information. 
 41.19     Sec. 43.  Minnesota Statutes 1998, section 72A.201, 
 41.20  subdivision 4a, is amended to read: 
 41.21     Subd. 4a.  [STANDARDS FOR PREAUTHORIZATION APPROVAL.] If a 
 41.22  policy of accident and sickness insurance or a subscriber 
 41.23  contract requires preauthorization approval for any nonemergency 
 41.24  services or benefits, the decision to approve or disapprove the 
 41.25  requested services or benefits must be communicated to the 
 41.26  insured or the insured's health care provider within ten three 
 41.27  business days of the preauthorization request provided that all 
 41.28  information reasonably necessary to make a decision on the 
 41.29  request has been made available to the insurer. 
 41.30     Sec. 44.  Minnesota Statutes 1998, section 256B.692, 
 41.31  subdivision 2, is amended to read: 
 41.32     Subd. 2.  [DUTIES OF THE COMMISSIONER OF HEALTH.] 
 41.33  Notwithstanding chapters 62D and 62N, a county that elects to 
 41.34  purchase medical assistance and general assistance medical care 
 41.35  in return for a fixed sum without regard to the frequency or 
 41.36  extent of services furnished to any particular enrollee is not 
 42.1   required to obtain a certificate of authority under chapter 62D 
 42.2   or 62N.  A county that elects to purchase medical assistance and 
 42.3   general assistance medical care services under this section must 
 42.4   satisfy the commissioner of health that the requirements of 
 42.5   chapter 62D, applicable to health maintenance organizations, or 
 42.6   chapter 62N, applicable to community integrated service 
 42.7   networks, will be met.  A county must also assure the 
 42.8   commissioner of health that the requirements of sections 
 42.9   62J.041; 62J.48; 62J.71 to 62J.73; 62M.01 to 62M.16; all 
 42.10  applicable provisions of chapter 62Q, including sections 62Q.07; 
 42.11  62Q.075; 62Q.105; 62Q.1055; 62Q.106; 62Q.11 62Q.109; 62Q.12; 
 42.12  62Q.135; 62Q.14; 62Q.145; 62Q.19; 62Q.23, paragraph (c); 62Q.30; 
 42.13  62Q.43; 62Q.47; 62Q.50; 62Q.52 to 62Q.56; 62Q.58 62Q.59; 62Q.64; 
 42.14  and 72A.201 will be met.  All enforcement and rulemaking powers 
 42.15  available under chapters 62D, 62J, 62M, 62N, and 62Q are hereby 
 42.16  granted to the commissioner of health with respect to counties 
 42.17  that purchase medical assistance and general assistance medical 
 42.18  care services under this section. 
 42.19     Sec. 45.  [REVISOR'S INSTRUCTION.] 
 42.20     In each section in Minnesota Statutes referred to in column 
 42.21  A, the revisor of statutes shall delete the reference in column 
 42.22  B and insert the reference in column C.  
 42.23       Column A                 Column B            Column C
 
 42.25       13.99, subd. 19c         62J.42              62J.41
 42.26       62J.301, subd. 1         62J.42              62J.41
 42.27       62J.301, subd. 4         62J.42              62J.41
 42.28       62J.311, subd. 2         62J.42              62J.41
 42.29       62J.321, subd. 1         62J.42              62J.41
 42.30       62J.321, subd. 4         62J.42              62J.41
 42.31       62J.321, subd. 5         62J.42              62J.41
 42.32       62J.321, subd. 8         62J.42              62J.41
 
 42.34     Sec. 46.  [REPEALER.] 
 42.35     Minnesota Statutes 1998, sections 62J.42; 62Q.105, 
 42.36  subdivision 4; 62Q.11; 62Q.30; 62Q.51, subdivision 4; and 
 42.37  62Q.58, are repealed. 
 42.38     Sec. 47.  [EFFECTIVE DATE.] 
 42.39     (a) Except as provided in paragraph (b), sections 1 to 46 
 42.40  are effective January 1, 2000, and apply to health plans issued 
 42.41  or renewed on or after that date. 
 43.1      (b) Sections 24, subdivision 5; 25, subdivision 2; and 41, 
 43.2   subdivision 4, are effective the day following final enactment.