.................... moves to amend H.F. No. 779 as follows:
Delete everything after the enacting clause and insert:
"Section 1. [62K.01] TITLE.
1.4This chapter may be cited as the "Minnesota Health Plan Market Rules."
Sec. 2. [62K.02] PURPOSE AND SCOPE.
1.6 Subdivision 1. Purpose. The market rules set forth in this chapter serve to clarify
1.7and provide guidance on the application of state law and certain requirements of the
1.8Affordable Care Act on all health carriers offering health plans in Minnesota, whether
1.9or not through the Minnesota Insurance Marketplace, to ensure fair competition for all
1.10health carriers in Minnesota, to minimize adverse selection, and to ensure that health
1.11plans are offered in a manner that protects consumers and promotes the provision of
1.12high-quality affordable health care, and improved health outcomes. This chapter contains
1.13the regulatory requirements as specified in Minnesota Statutes, section 62V.05, subdivision
1.145, paragraph (b), if enacted in 2013 H.F. No. 5/S.F. No. 1 and, upon enactment, shall fully
1.15satisfy the requirements of Minnesota Statutes, section 62V.05, subdivision 5, paragraph
1.16(b), if enacted in 2013 H.F. No. 5/S.F. No. 1.
1.17 Subd. 2. Scope. (a) This chapter applies only to health plans offered in the
1.18individual market or the small group market, except short-term coverage as defined in
1.19section 62A.65, subdivision 7.
1.20(b) This chapter applies to health carriers with respect to individual health plans and
1.21small group health plans, unless otherwise specified.
1.22(c) If a health carrier issues or renews individual or small group health plans in
1.23other states, this chapter applies only to health plans issued or renewed in this state to a
1.24Minnesota resident, or to cover a resident of the state, or issued or renewed to a small
1.25employer that is actively engaged in business in this state, unless otherwise specified.
2.1(d) This chapter does not apply to short-term coverage as defined in section 62A.65,
Sec. 3. [62K.03] DEFINITIONS.
2.4 Subdivision 1. Applicability. For purposes of this chapter, the terms defined in this
2.5section have the meanings given.
2.6 Subd. 2. Affordable Care Act. "Affordable Care Act" means the federal Patient
2.7Protection and Affordable Care Act, Public Law 111-148, as amended, including the
2.8federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and
2.9any amendments to it, or guidance and regulations issued under those acts.
2.10 Subd. 3. Dental plan. "Dental plan" means a dental plan as defined in section
2.1162Q.76, subdivision 3.
2.12 Subd. 4. Enrollee. "Enrollee" means a natural person covered by a health plan and
2.13includes an insured policyholder, subscriber, contract holder, member, covered person,
2.14or certificate holder.
2.15 Subd. 5. Health carrier. "Health carrier" means a health carrier as defined in
2.16section 62A.011, subdivision 2.
2.17 Subd. 6. Health plan. "Health plan" means a health plan as defined in section
2.1862A.011, subdivision 3.
2.19 Subd. 7. Individual health plan. "Individual health plan" means an individual
2.20health plan as defined in section 62A.011, subdivision 4.
2.21 Subd. 8. Minnesota Insurance Marketplace. "Minnesota Insurance Marketplace"
2.22means the Minnesota Insurance Marketplace as defined in Minnesota Statutes, section
2.2362V.02 if enacted in 2013 H.F. No. 5/S.F. No. 1.
2.24 Subd. 9. Preferred provider organization. "Preferred provider organization"
2.25means a health plan that provides discounts to enrollees or subscribers for services they
2.26receive from certain health care providers.
2.27 Subd. 10. Small group health plan. "Small group health plan" means a health plan
2.28issued by a health carrier to a small employer as defined in section 62L.02, subdivision 26.
2.29 Subd. 11. Qualified health plan. "Qualified health plan" means a health plan that
2.30meets the definition in section 1301(a) of the Affordable Care Act and has been certified
2.31by the board of the Minnesota Insurance Marketplace in accordance with Minnesota
2.32Statutes, chapter 62V if enacted in 2013 H.F. No. 5/S.F. No. 1 to be offered through the
2.33Minnesota Insurance Marketplace.
Sec. 4. [62K.04] MARKET RULES; VIOLATION.
3.1 Subdivision 1. Compliance. (a) A health carrier issuing an individual health plan
3.2issued to a Minnesota resident or a small group health plan issued to provide coverage to
3.3a small employer that is actively engaged in business in Minnesota shall meet all of the
3.4requirements set forth in this chapter. The failure to meet any of the requirements under
3.5this chapter constitutes a violation of section 72A.20.
3.6(b) The requirements of this chapter do not apply to individual or small group health
3.7plans issued before January 1, 2015.
3.8(c) The requirements of this chapter do not apply to short-term coverage as defined
3.9in section 62A.65.
3.10 Subd. 2. Penalties. In addition to any other penalties provided by the laws of this
3.11state or by federal law, a health carrier or any other person found to have violated any
3.12requirement of this chapter may be subject to the administrative procedures, enforcement
3.13actions, and penalties provided under section 45.027 and chapters 62D and 72A.
Sec. 5. [62K.05] FEDERAL ACT; COMPLIANCE REQUIRED.
3.15A health carrier shall comply with all provisions of the Affordable Care Act to
3.16the extent that it imposes a requirement that applies in this state. Compliance with any
3.17provision of the Affordable Care Act is required as of the effective date established for
3.18that provision in the federal act, except as otherwise specifically stated earlier in state law.
Sec. 6. [62K.06] METAL LEVEL MANDATORY OFFERINGS.
3.20 Subdivision 1. Identification. A health carrier that offers individual or small group
3.21health plans in Minnesota must provide documentation to the commissioner of commerce
3.22to justify actuarial value levels as specified in section 1302 of the Affordable Care Act for
3.23all individual and small group health plans offered inside and outside of the Minnesota
3.25 Subd. 2. Minimum levels. (a) A health carrier that offers any individual or small
3.26group health plan, either inside or outside of the Minnesota Insurance Marketplace, must
3.27offer at a minimum a silver level and a gold level health plan to Minnesota residents, as
3.28well as for each health plan offered, a health plan in which the only enrollees are children,
3.29who, as of the beginning of a policy year, have not attained the age of 21 years.
3.30(b) A health carrier with less than five percent market share in either the individual
3.31or small group market in Minnesota is exempt from paragraph (a), until January 1, 2020,
3.32unless the health carrier offers a qualified health plan through the Minnesota Insurance
3.33Marketplace. If the health carrier offers a qualified health plan through the Minnesota
3.34Insurance Marketplace, the health carrier must comply with paragraph (a).
4.1 Subd. 3. Minnesota Insurance Marketplace restriction. The Minnesota Insurance
4.2Marketplace may not, by contract or otherwise, mandate the types of health plans to be
4.3offered by a health carrier to individuals or small employers purchasing health plans
4.4outside of the Minnesota Insurance Marketplace. For purposes of this section, "health
4.5plan" includes coverage that is excluded under section 62A.011, subdivision 3, clause (6).
4.6 Subd. 4. Metal level defined. For purposes of this section, the metal levels are
4.7defined in section 62Q.81, subdivision 1, paragraph (c).
4.8 Subd. 5. Enforcement. The commissioner of commerce shall enforce this section.
Sec. 7. [62K.07] INFORMATION DISCLOSURES.
4.10(a) A health carrier offering individual or small group health plans must submit the
4.11following information in a format determined by the commissioner of commerce:
4.12(1) claims payment policies and practices;
4.13(2) periodic financial disclosures;
4.14(3) data on enrollment;
4.15(4) data on disenrollment;
4.16(5) data on the number of claims that are denied;
4.17(6) data on rating practices;
4.18(7) information on cost-sharing and payments with respect to out-of-network
4.20(8) other information required by the secretary of the United States Department of
4.21Health and Human Services under the Affordable Care Act.
4.22(b) A health carrier offering an individual or small group health plan must comply
4.23with all information disclosure requirements of all applicable state and federal law,
4.24including the Affordable Care Act. To the extent that both state and federal law impose
4.25information disclosures or standards with respect to a health plan, the health carrier must
4.26comply with the disclosure requirement that provides the greater consumer protection to
4.28(c) The commissioner of commerce shall enforce this section.
Sec. 8. [62K.08] MARKETING STANDARDS.
4.30 Subdivision 1. General. A health carrier offering individual or small group health
4.31plans must comply with all applicable provisions of the Affordable Care Act, including,
4.32but not limited to, the following:
4.33(1) compliance with all state laws pertaining to the marketing of individual or small
4.34group health plans; and
5.1(2) establishing marketing practices and benefit designs that will not have the effect of
5.2discouraging the enrollment of individuals with significant health needs in the health plan.
5.3 Subd. 2. Specific requirements. (a) Any written marketing materials must include
5.4a statement of enrollee information and rights as described in chapter 62D.
5.5(b) Detailed marketing materials must affirmatively disclose all exclusions and
5.6limitations on the services offered.
5.7(c) No market materials may lead consumers to believe that all health care needs
5.8will be covered.
5.9(d) All marketing materials must contain the following language in bold print: This
5.10health care plan may not cover all your health care expenses, read your contract
5.11carefully to determine which expenses are covered.
5.12 Subd. 3. Enforcement. The commissioner of commerce shall enforce this section.
Sec. 9. [62K.09] ACCREDITATION STANDARDS.
5.14 Subdivision 1. Accreditation; general. (a) A health carrier that offers any
5.15individual or small group health plans in Minnesota outside of the Minnesota Insurance
5.16Marketplace must be accredited in accordance with this subdivision. A health carrier
5.17must obtain accreditation through URAC, the National Committee for Quality Assurance
5.18(NCQA), or any entity recognized by the United States Department of Health and Human
5.19Services for accreditation of health insurance issuers or health plans by January 1,
5.202018. Proof of accreditation must be submitted to the commissioner of health in a form
5.21prescribed by the commissioner of health.
5.22(b) A health carrier with less than five percent market share in either the individual
5.23or small group market in Minnesota is exempt from this subdivision until January 1, 2020.
5.24 Subd. 2. Accreditation; Minnesota Insurance Marketplace. (a) The Minnesota
5.25Insurance Marketplace shall require all health carriers offering a qualified health
5.26plan through the Minnesota Insurance Marketplace to obtain the appropriate level of
5.27accreditation no later than the third year after the first year the health carrier offers a
5.28qualified health plan through the Minnesota Insurance Marketplace. A health carrier
5.29must take the first step of the accreditation process during the first year in which it offers
5.30a qualified health plan. A health carrier that offers a qualified health plan on January 1,
5.312014, must obtain accreditation by the end of the 2016 plan year.
5.32(b) To the extent a health carrier cannot obtain accreditation due to low volume of
5.33enrollees, an exception to this accreditation criterion may be granted by the Minnesota
5.34Insurance Marketplace until such time as the health carrier has a sufficient volume of
6.1 Subd. 3. Enforcement. The commissioner of health shall enforce this section.
Sec. 10. [62K.10] GEOGRAPHIC ACCESSIBILITY; PROVIDER NETWORK
6.4 Subdivision 1. Applicability. This section applies to all health carriers offering an
6.5individual and small group health plan that designates a network or networks of contracted
6.6providers, or is a preferred provider organization.
6.7 Subd. 2. Primary care; mental health services; general hospital services.
6.8Primary care, mental health, and general hospital services must be available to enrollees
6.9within 30 miles or 30 minutes' travel time to the nearest participating or preferred provider.
6.10 Subd. 3. Other health services. Specialty physician services, ancillary services,
6.11specialized hospital services, and all other covered health services must be available
6.12to enrollees within 60 miles or 60 minutes' travel time to the nearest participating or
6.14 Subd. 4. Network adequacy. Each designated provider network must include a
6.15sufficient number and type of providers to ensure that covered services are available
6.16to all enrollees without unreasonable delay. In determining network adequacy, the
6.17commissioner of health shall consider availability of services, including the following:
6.18(1) primary care physician services are available and accessible 24 hours per day,
6.19seven days per week, within the network area;
6.20(2) a sufficient number of primary care physicians have hospital admitting privileges
6.21at one or more participating hospitals within the network area so that necessary admissions
6.22are made on a timely basis consistent with generally accepted practice parameters;
6.23(3) specialty physician service is available through the network or contract
6.25(4) to the extent that primary care services are provided through primary care
6.26providers other than physicians, and to the extent permitted under applicable scope of
6.27practice in state law for a given provider, these services shall be available and accessible;
6.29(5) the network has available, either directly or through arrangements, appropriate
6.30and sufficient personnel, physical resources, and equipment to meet the projected needs of
6.31enrollees for covered health care services.
6.32 Subd. 5. Waiver. A health carrier or preferred provider organization may apply to
6.33the commissioner of health for a waiver of the requirements in subdivision 2 or 3 if it is
6.34unable to meet the statutory requirements. A waiver application must be made on a form
7.1provided by the commissioner and must demonstrate with specific data that the requirement
7.2of subdivision 2 or 3 is not feasible in a particular service area or part of a service area.
7.3 Subd. 6. Referral centers. Subdivisions 2 and 3 shall not apply if an enrollee
7.4is referred to a referral center for health care services. A referral center is a medical
7.5facility that provides highly specialized medical care, including but not limited to organ
7.6transplants and bariatric surgery. A health carrier or preferred provider organization may
7.7consider the volume of services provided annually, case mix, and severity adjusted
7.8mortality and morbidity rates in designating a referral center.
7.9 Subd. 7. Essential community providers. Each health carrier must comply with
7.10section 62Q.19 to ensure reasonable and timely access to covered services for low-income,
7.11high-risk, special-needs individuals or those living in a medical shortage area.
7.12 Subd. 8. Enforcement. The commissioner of health shall enforce this section.
Sec. 11. [62K.11] BALANCE BILLING PROHIBITED.
7.14(a) A network provider is prohibited from billing an enrollee for any amount in
7.15excess of the allowable amount the health carrier has contracted for with the provider
7.16as total payment for the health care service. A network provider is permitted to bill an
7.17enrollee the approved co-payment deductible, or coinsurance.
7.18(b) A network provider is permitted to bill an enrollee for services not covered by
7.19the enrollee's health plan as long as the enrollee agrees in writing in advance before the
7.20service if performed to pay for the noncovered service.
Sec. 12. [62K.12] QUALITY ASSURANCE AND IMPROVEMENT.
7.22(a) All health carriers offering an individual health plan or small group health
7.23plan must have a written internal quality assurance and improvement program that, at a
7.25(1) provides for ongoing evaluation of the quality of health care provided to its
7.27(2) periodically reports the evaluation of the quality of health care to the health
7.28carrier's governing body;
7.29(3) follows policies and procedures for the selection and credentialing of network
7.30providers that is consistent with community standards;
7.31(4) conducts focused studies directed at problems, potential problems, or areas
7.32with potential for improvements in care;
7.33(5) conducts enrollee satisfaction surveys and monitors oral and written complaints
7.34submitted by enrollees or members; and
8.1(6) collects and reports Health Effectiveness Data and Information Set (HEDIS)
8.2measures and conducts other quality assessment and improvement activities as directed
8.3by the commissioner of health.
8.4 (b) The commissioner of health shall submit a report to the chairs and ranking
8.5minority members of senate and house of representatives committees with primary
8.6jurisdiction over commerce and health policy by February 15, 2015, with recommendations
8.7for specific quality assurance and improvement standards for all Minnesota health carriers.
8.8(c) The commissioner of health shall enforce this section.
Sec. 13. [62K.13] SERVICE AREA REQUIREMENTS.
8.10(a) Health carriers must offer individual and small group health plans in service areas
8.11that are at least the entire geographic area of a county unless serving a smaller geographic
8.12area is necessary, nondiscriminatory, and in the best interest of enrollees. The service area
8.13for any individual or small group health plan must be established without regard to racial,
8.14ethnic, language, or health status-related factors, or other factors that exclude specific
8.15high-utilizing, high-cost, or medically underserved populations.
8.16(b) If a health carrier requests to serve less than the entire county, the request
8.17must be made to the commissioner of health on a form and manner determined by the
8.18commissioner and must provide specific data demonstrating that the service area is not
8.19discriminatory, is necessary, and is in the best interest of enrollees.
Sec. 14. [62K.14] NETWORK PROVIDER DIRECTORIES.
8.21Health carriers offering qualified health plans through the Minnesota Insurance
8.22Marketplace must submit information on network providers to the Minnesota Insurance
8.23Marketplace. The Minnesota Insurance Marketplace and the commissioner of health must
8.24collaborate to determine the form and manner in which this information shall be provided
8.25to the Minnesota Insurance Marketplace and the commissioner of health. Health carriers
8.26must provide this information at least quarterly and more frequently as determined by the
8.27Minnesota Insurance Marketplace or the commissioner of health.
Sec. 15. [62K.15] LIMITED SCOPE DENTAL PLANS.
8.29(a) Limited scope dental plans must be offered on a guaranteed issue basis with
8.30premiums rated on allowable rating factors used for health plans. The commissioner
8.31of commerce shall enforce this paragraph.
8.32(b) Limited scope dental plans must ensure dental services are available within 30
8.33miles or 30 minutes' travel time. The commissioner of health shall enforce this paragraph.
9.1(c) Health carriers offering limited scope dental plans must comply with this section
9.2and sections 62K.07, 62K.08, 62K.13, and 62K.14.
Amend the title accordingly