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H.F. No. 779 - Affordable Care Act Conformity and Health Market Rules (Unofficial Engrossment)
 
Author: Senator Tony Lourey
 
Prepared By:
 
Date: May 14, 2013



 

H.F. 779 makes regulatory changes to state law to conform to the Affordable Care Act ("ACA").  H.F. 779 also establishes market rules for health carriers offering health plans in the individual and small group markets in Minnesota.

Article 1: Affordable Care Act Conformity

Sections 1 and 2 (43A.23, subdivision 1 and 43A.317, subdivision 6) change the definition of dependent child in chapter 43A (state employee group insurance plan).

Section 3 (60A.08, subdivision 15)  requires the commissioner of commerce for all rate increases subject to review that are filed with the commissioner on or after September 1, 2011, to acknowledge receipt of the information; acknowledge that the rate filing is pending review; provide public access to certain information related to the rate increase subject to review; and to provide notice to the public of the review of the proposed rate which states that the public has 30 days to submit written comments to the commissioner on the rate filing.

Sections 4 to 11 (62A.011) add or amend the following definitions in chapter 62A: Affordable Care Act, grandfathered plan, group health plan, health plan, individual health plan, individual market, Minnesota Insurance Marketplace, and qualified health plan.

Section 12 (62A.02, subdivision 8) states that no health plan shall be offered through the Minnesota Insurance Marketplace until a copy of its form and the premium rates pertaining to the form have been filed with the commissioner of commerce and the commissioner has reviewed the health plan for compliance with the certification requirements of the Marketplace.

Section 13 (62A.03, subdivision 1) makes a conforming change to the new definition of dependent children.

Section 14 (62A.04, subdivision 2) make a conforming change with regard to grace periods.  Requires certain health plans that are required to comply with the ACA to include a grace period provision that is no less restrictive than what is required under the ACA.

Section 15 (62A.047) makes a conforming change to this section stating that the policy may not apply preexisting condition limitations to individuals under the age of 19 with the exception of grandfathered plan coverage.

Section 16 (62A.049) removes the failure to obtain prior authorization exception to admissions for treatment of chemical dependency and nervous and mental disorders.

Section 17 (62A.136) makes a technical change removing a section that is being repealed.

Section 18 (62A.149, subdivision 1) removes the ability of an individual to elect to refuse benefits in exchange for an appropriate reduction in premiums or charges under the policy or plan.

Section 19 (62A.17, subdivision 2) specifies individuals age 19 or older in this section (continuation coverage).

Sections 20 and 21 (62A.17, subdivision 6 and 62A.21, subdivision 2b) strike language requiring a health carrier to offer a conversion policy.

Section 22 (62A.28, subdivision 2) modifies the required coverage for scalp hair prosthesis to one per benefit year.

Section 23 (62A.302) specifies the ACA required coverage for dependents.  Requires any health plan that provides dependent coverage of children must make the coverage available until the child reaches the age of 26.

Section 24 (62A.3021) defines dependent for plans other than health plans.

Sections 25 to 29 make conforming changes to 62A.65 (individual market regulation).

Section 25 (62A.615) specifies that a health plan cannot restrict coverage for a preexisting condition for an individual under the age of 19 except under a grandfathered plan.

Section 26 (62A.65, subdivision 3) modifies the premium rate restrictions in accordance with the ACA.  Permits premium rate variations based on age, geographic area, and tobacco use.  Premiums charged shall not be adjusted more frequently than once a year, with the exception of specified changes. 

Section 27 (62A.65, subdivision 3a) requires a health carrier to make certain disclosures to be made as part of its solicitation and sales materials.

Section 28 (62A.65, subdivision 3b) requires a health carrier to consider all enrollees in all health plans offered in the individual market to be members of a single risk pool, with the exception of enrollees in grandfathered plans.

Section 29 (62A.65, subdivision 5) makes a conforming change in this section that states that no individual health plan may be offered or sold with a preexisting condition limitation or exclusion, with the exception of grandfathered plans.

Section 30 (62A.65, subdivision 6) states that guaranteed issue is required for all health plans issued on or after January 1, 2014, except for grandfathered plans.

Section 31 (62A.65, subdivision 7) strikes unnecessary language with regard to short term coverage counting toward a preexisting condition limitation.

Sections 32 and 33 (62C) make the necessary conforming changes to chapter 62C (nonprofit health services plan corporations).

Sections 34 to 36 (62D) make the necessary conforming changes to chapter 62D (health maintenance organizations).

Sections 37 to 42 (62E) make the necessary conforming changes to chapter 62E (comprehensive health insurance).

Section 43 (62H.04) states that a joint self insurance plan must comply with the ACA to the extent that it applies to these plans.

Sections 44 to 57 (62L) make conforming changes to the chapter 62L (small employer insurance).

Section 44 (62L.02, subdivision 11) makes a conforming change to the definition of dependent.

Section 45 (62L.02, subdivision 14a) makes a conforming change to the definition of guaranteed issue.

Section 46 (62L.02, subdivision 17a) adds a definition of individual health plan.

Section 47 (62L.02, subdivision 26) changes the definition of small employer to state that a small employer employs at least one, not including a sole proprietor, but no more than 50 employees.

Section 48 (62L.03, subdivision 1) makes conforming change and strikes obsolete language.

Section 49 (62L.03, subdivision 3) specifies that waiver of coverage may include unaffordability as specified under the ACA and provides that this section does not apply to health plans offered through the Minnesota Insurance Marketplace.

Section 50 (62L.03, subdivision 4) makes conforming changes to the underwriting restrictions.

Section 51 (62L.03, subdivision 6) makes a conforming change regarding underwriting restrictions and MCHA enrollees.

Sections 52 and 53 (62L.045) make conforming changes regarding qualified associations.

Section 54 (62L.05, subdivision 10) makes a conforming change to medical expense reimbursement and a reference to maximum lifetime benefits.

Section 55 (62L.06) makes conforming changes to the underwriting rating practices.

Section 56 (62L.08) makes conforming changes to premium rate restrictions.  Permits premium variations based on age, geographic area and tobacco use.

Section 57 (62L.12, subdivision 2) specifies that a health carrier may sell an individual health plan if coverage provided to the small employer is determined to be unaffordable under the ACA.

Sections 58 and 59 (62M) make conforming changes to chapter 62M (utilization review).

Section 58 (62M.05, subdivision 3a) requires the written notification of an initial determination not to certify to be provided in a culturally and linguistically appropriate manner consistent with the ACA.

Section 59 (62M.06, subdivision 1) states that as part of the appeals process for determinations not to certify the utilization review organization must allow the enrollee to review information relied on in the course of the appeal, present evidence and testimony as part of the appeals process and receive continued coverage pending the outcome of the appeals process.

Sections 60 to 90 makes conforming changes to chapter 62Q (health plan companies).

Sections 60 to 67 (62Q.01) add the following definitions to chapter 62Q: Affordable Care Act; grandfathered health plan; group health plan; individual health plan; bone fide association; life threatening condition;  primary care provider;  and dependent child to the limiting age.

Section 68 (62Q.021) requires health plan companies to comply with the ACA.

Section 69 (62Q.17, subdivision 6) strikes language permitting purchasing pools to create tiers within the pool.

Section 70 (62Q.18) states that no health plan company may offer, issue, or sell a health plan that does not make coverage available on a guaranteed issue basis in accordance with the ACA.

Section 71 (62Q.186) contains prohibitions on rescissions of health plans.

Sections 72 and 73 (62Q.23 and 62Q.43) make a conforming change regarding dependent children.

Section 74 (62Q.46) is a new section that sets forth the ACA requirements for preventive items and services.

Subdivision 1

Paragraph (a) defines preventive items and services. 

Paragraph (b) states that a health plan company is prohibited from imposing cost sharing for preventive items and services provided by a participating provider.  Permits a health plan company that has a network of providers to exclude coverage or impose cost sharing for preventive items and services that are delivered by out of network providers.

Paragraph (c) states that a health plan company is not required to cover items or services if the recommendation or guideline is no longer included as a preventive item or service.  A health plan company is required to annually determine whether additional items or services must be covered without cost sharing or whether any items or services are no longer required to be covered.

Paragraph (d) permits a health plan company to use reasonable medical management techniques to determine frequency, method, treatment or setting for a preventive item or service to the extent not specified in a recommendation or guideline.

Paragraph (e) excludes grandfathered plan coverage from this section.

Subdivision 2  

Paragraph (a) permits a health plan company to impose cost sharing with respect to an office visit if a preventive item or service is billed separately or is not tracked separately as individual encounter data from the office visit.

Paragraph (b) prohibits a health plan company from imposing cost sharing with respect to an office visit if the preventive item or service is not billed separately or is not tracked separately from the office visit and the primary purpose of the visit is the delivery of the preventive item or service.

Paragraph (c) permits a health plan company to impose cost sharing with respect to an office visit if a preventive item or service is not billed separately or tracked separately as individual encounter data from the office visit and the primary purpose of the visit is not for the delivery of the preventive item or service.

Subdivision 3 states that a health plan company is not prohibited from providing coverage for items and services in addition to those specified in the ACA.

Section 75 (62Q.47) requires all health plans to meet the requirements of the federal Mental Health Parity Act, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, the ACA, and any amendments or guidance and regulations under those acts.

Section 76 (62Q.52) modifies the section that provides direct access to obstetric and gynecologic services.  Requires the health plan company to treat the provision of obstetrical and gynecological care and the ordering of related items and services by a participating health care professional who specializes in obstetrics or gynecology as the authorization of a primary care health care professional.  The health plan company may require the health care professional to adhere to the health plan company’s policies and procedures including procedures for obtaining prior authorization and for providing services in accordance to a treatment plan approved by the health plan company.

Section 77 (62Q.526) provides the requirements for participation in approved clinical trials.

Section 78 (62Q.55) contains requirements for access to emergency services.

Section 79 (62Q.57) regulates choice of a primary care provider when the health plan provides for designation of one.

Section 80 (62Q.677) contains the prohibitions on lifetime and annual limits.

Sections 81 to 86 (62Q.68-62Q.73) contain conforming changes for complaint resolution, appeals, and external review of adverse determinations.

Section 87 (62Q.75, subdivision 1) modifies the definition of a “clean claim”.

Section 88 (62Q.80) is a conforming change related to dependent age.

Section 89 (62Q.81) requires health plans offered by health plan companies  to cover the essential health benefits required by the ACA. Essential health benefits are defined.

Section 90 (62Q.82) requires health plan companies to provide a summary of benefits and coverage explanation as required by the ACA.

Section 91 (72A.20, subdivision 35) is a conforming change related to policy limits.

Section 92 (471.61) is a conforming change related to dependents.

Section 93 repeals statutes that are no longer needed.

Article 2: Market Rules

Section 1 (62D.124, subdivision 4) specifies in chapter 62D (health maintenance organization) that the section on geographic accessibility does not apply to individual or small group health plans effective January 1, 2014.

Section 2 (62K.01) states that chapter 62K may be cited as the “Minnesota Health Plan Market Rules.”

Section 3 (62K.02) states the purpose and scope of the chapter.

Section 4 (62K.03) defines the following terms: Affordable Care Act; dental plan; enrollee; health carrier; health plan; individual health plan; limited-scope pediatric dental plan; Minnesota Insurance Marketplace; preferred provider organization; qualified health plan; and small group health plan.

Section 5 (62K.04) Requires a health carrier issuing specified health plans to meet all of the requirements of this chapter.  A health carrier or any other person found to have violated the requirements of this chapter shall be subject to the administrative procedures, enforcement actions and penalties provided under sections 45.027 (commissioner of commerce general powers); chapter 62D (health maintenance organizations); and 72A (insurance industry trade practices).

Section 6 (62K.05) requires health carriers to comply with the ACA to the extent it imposes a requirement that applies to this state.

Section 7 (62K.06) establishes the mandatory metal level offerings.

Subdivision 1 requires a health carrier that offers individual or small group health plans in Minnesota to provide documentation to the commissioner of commerce to justify actuarial value levels as specified in the ACA for all individual and small group market health plans offered inside and outside of the Minnesota Insurance Marketplace.

Subdivision 2 requires a health carrier that offers a catastrophic plan or a bronze level plan in either the individual or small group market within a service area to also offer a silver and gold level plan in that market and within that service area.  A health carrier with less than 5% of the individual or small group market is exempt from this requirement until January 1, 2017, unless it offers a plan through the Minnesota Insurance Marketplace.

Subdivision 3 specifies that the Minnesota Insurance Marketplace may not mandate the types of health plans to be offered by a health carrier to individuals or small employers purchasing health plans outside of the Minnesota Insurance Marketplace.

Subdivision 4 defines metal level and catastrophic plans.

Subdivision 5 gives the commissioner of commerce enforcement authority for this section.

Section 8 (62K.07)  Requires health carriers offering individual or small group health plans in this state to comply with all state and federal applicable information disclosure requirements. Marketing practices and benefit designs must not have the effect of discouraging the enrollment of individuals with significant health needs.  The commissioner of commerce enforces this section.

Section 9 (62K.08) requires health carriers offering a health plan in this state to comply with all applicable marketing provisions of the Affordable Care Act including state laws and establishing marketing practices and benefit designs that will not have the effect of discouraging the enrollment of individuals with significant health needs in the health plan. Specific requirements are provided. The commissioner of commerce enforces this section.

Section 10 (62K.09) establishes accreditation standards.

Subdivision 1 requires a health carrier that offers individual or small group health plans in Minnesota outside of the Minnesota Insurance Marketplace to be accredited through URAC, NCQA, or any other entity recognized by the U. S. Department of Health and Human Services for accreditation of health insurance issuers or health plans, by January 1, 2018.  Exempts health carriers from this requirement if the health carrier rents a provider network, unless it is part of a holding company, that in aggregate exceeds ten percent market share in the individual or small group market in Minnesota.

Subdivision 2 specifies that the Minnesota Insurance Marketplace shall require health carriers offering a qualified health plans through the Minnesota Insurance Marketplace to obtain appropriate level of accreditation no later than the third year after the first year the health carrier offers a qualified health plan.

Subdivision 3 requires a health carrier to comply with a request from the commissioner of health to confirm accreditation.

Subdivision 4 states that the commissioner of health shall enforce this section.

Section 11 (62K.10) establishes geographic accessibility and provider network adequacy requirements.

Subdivision 1 states that this section applies to all health carriers that designate a network or networks of contracted providers or is a preferred provider organization.

Subdivision 2 requires primary care, mental health, and general hospital services to be available to enrollees and covered persons within 30 miles or 30 minutes’ travel time to the nearest participating or preferred  provider.

Subdivision 3 requires other health care services to be available to enrollees and other covered persons within 60 miles or 60 minutes’ travel time to the nearest participating or preferred provider.

Subdivision 4 requires that each designated provider network has a sufficient number of providers to ensure that services are available to enrollees without unreasonable delay.

Subdivision 5 permits a health carrier or preferred provider organization to apply to the commissioner of health for a waiver of the requirements in subdivision 2 or 3 if it is unable to meet the requirements.  The waiver application must demonstrate with specific data that the requirements of subdivision 2 or 3 is not feasible in a particular service area or part of a service area.

Subdivision 6 states that subdivisions 2 or 3 do not apply if an enrollee is referred to a referral center for health care services.  States that a referral center is a facility that provides highly specialized medical care and that a health carrier or preferred provider organization may consider the volume of services provided annually, case mix, and severity adjusted mortality and morbidity rates in designating a referral center.

Subdivision 7 requires a health carrier or preferred organization to comply with section 62Q.19 (essential community providers).

Subdivision 8 provides that the commissioner of health enforces this section.

Section 12 (62K.11) prohibits a network provider from billing an enrollee for any amount in excess of the allowable amount the health carrier has contracted for with the provider as total payment for the health care service.  Permits a network provider to bill an enrollee for any approved cost-sharing amount.

Section 13 (62K.12) requires health carriers offering an individual or small group health plan to have a written internal quality assurance and improvement program.  Exempts a health carrier that rents a provider network from this section, unless it is part of a holding company that in aggregate exceeds ten percent market share in either the individual or small group market.  This section also waives this requirement for health carriers that have obtained accreditation through the URAC or have achieved an excellent or commendable level ranking from NCQA.  The commissioner of health shall enforce this section.

Section 14 (62K.13) requires any health carrier that offers an individual or small group health plan must offer the plan in a service area that is at least the entire geographic area of a county, unless serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of the enrollees.  Permits a health carrier to submit a request to the commissioner of health to serve an area that is less than a county and must provide specific data with the request.  The commissioner of health shall enforce this section. 

Section 15 (62K.14) requires limited scope dental plans to be offered on a guaranteed issue basis with premiums rated on allowable rating factors used for health plans.  Dental plans are also required to ensure dental services are available within 30 miles or 30 minutes’ travel time.  The commissioner of health enforces this paragraph.  Health carriers offering limited scope dental plans are required to comply with sections 62K.06 (marketing standards) and 62K.08 (service area requirements).

Section 16 (62K.15) states that health carriers offering individual health plans must limit annual enrollment to the annual open enrollment periods for the Minnesota Insurance Marketplace.  Requires health carriers to inform applicants at the time of application and enrollees at least annually of the open and special enrollment periods.  The commissioner of commerce shall enforce this section.

Section 17 (62Q.19) designates hospitals that serve children; provides intentive specialty pediatric services; and serves children from at least half the counties in Minnesota as an essential community provider.

Effective Dates:  Sections 1, 2, 3, 4, 9, 11, 15, and 17 are effective January 1, 2014.  Sections 5, 6, 7, 8, 10, 12, 13, 14, and 16 are effective January 1, 2015.

KC:dv

 

 

 
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