piers109uk/MN-Statutes huggingface dataset:
62L.23 SUSPENSION OF REINSURANCE OPERATIONS; REACTIVATION.
The commissioner may, by order, suspend the operation of sections 62L.13 to 62L.22, upon receipt of a recommendation for suspension from the association board of directors. The order is effective 30 days after publication in the State Register.
Upon the issuance of an order issued pursuant to subdivision 1, the association shall suspend its operations in an orderly manner supervised by the commissioner and shall provide for the proper storage of the association's records. Notwithstanding the provisions of subdivision 1, the association may continue to levy assessments under section 62L.22 for the purpose of satisfying the association's presuspension expenses and the expenses associated with the association's suspension activities pursuant to this subdivision. The assessments must be approved by the commissioner.
Effective upon the effective date of an order issued pursuant to subdivision 1, reinsurance must be terminated for any person reinsured by the association pursuant to section 62L.18. No health carrier may cancel or fail to renew a health benefit plan for any person whose reinsurance with the association has been terminated subsequently to the issuance of an order pursuant to subdivision 1 solely because of the termination of reinsurance.
The commissioner may, by order, reactivate the operation of sections 62L.13 to 62L.22, on a finding that the private market for reinsurance of health benefit plans has failed and that commercial reinsurance is unavailable to health carriers operating in the small employer market in Minnesota. The commissioner may not make findings or issue an order pursuant to this subdivision until a hearing is held pursuant to chapter 14.
After issuance of any order pursuant to subdivision 4, the commissioner shall immediately appoint an interim board of directors of the association. The terms of members of this interim board must be for a period not to exceed 18 months. The board shall cause the reinsurance operations of the association to be resumed within 180 days of an order issued pursuant to subdivision 4.
If the commissioner issues an order pursuant to subdivision 4, any health carrier may elect to participate in the reinsurance association, notwithstanding any departicipation by the health carrier within the preceding five years that, pursuant to section 62L.17, would have otherwise prohibited the health carrier's participation.
62N.01 CITATION AND PURPOSE.
This chapter may be cited as the "Minnesota Community Integrated Service Network Act."
[Repealed, 1997 c 225 art 2 s 63]
62N.02 DEFINITIONS.
The definitions in this section apply to this chapter.
[Repealed, 1997 c 225 art 2 s 63]
[Repealed, 1997 c 225 art 2 s 63]
"Commissioner" means the commissioner of health or the commissioner's designated representative.
(a) "Community integrated service network" or "community network" means a formal arrangement licensed by the commissioner under section 62N.25 for providing prepaid health services to enrolled populations of 50,000 or fewer enrollees, including enrollees who are residents of other states.
(b) [Expired]
[Repealed, 1997 c 225 art 2 s 63]
[Repealed, 1997 c 225 art 2 s 63]
"Enrollee" means an individual, including a member of a group, to whom a network is obligated to provide health services under this chapter.
[Repealed, 1997 c 225 art 2 s 63]
"Health carrier" has the meaning given in section 62A.011.
[Repealed, 1997 c 225 art 2 s 63]
[Repealed, 1997 c 225 art 2 s 63]
[Repealed, 1997 c 225 art 2 s 63]
[Repealed, 1997 c 225 art 2 s 63]
"Price" means the actual amount of money paid, after discounts or other adjustments, by the person or organization paying money to buy health care coverage and health care services. "Price" does not mean the cost or costs incurred by a network or other entity to provide health care services to individuals.
[Repealed, 1997 c 225 art 2 s 63]
62M.01 CITATION, JURISDICTION, AND SCOPE.
This chapter may be cited as the "Minnesota Utilization Review Act of 1992."
This chapter applies to any insurance company licensed under chapter 60A to offer, sell, or issue a policy of accident and sickness insurance as defined in section 62A.01; a health service plan licensed under chapter 62C; a health maintenance organization licensed under chapter 62D; the Minnesota Comprehensive Health Association created under chapter 62E; a community integrated service network licensed under chapter 62N; an accountable provider network operating under chapter 62T; a fraternal benefit society operating under chapter 64B; a joint self-insurance employee health plan operating under chapter 62H; a multiple employer welfare arrangement, as defined in section 3 of the Employee Retirement Income Security Act of 1974 (ERISA), United States Code, title 29, section 1103, as amended; a third-party administrator licensed under section 60A.23, subdivision 8, that provides utilization review services for the administration of benefits under a health benefit plan as defined in section 62M.02; any other entity that provides, offers, or administers hospital, outpatient, medical, prescription drug, or other health benefits to individuals treated by a health professional under a policy, plan, or contract; or any entity performing utilization review on behalf of a business entity in this state pursuant to a health benefit plan covering a Minnesota resident.
(a) Nothing in this chapter applies to review of claims after submission to determine eligibility for benefits under a health benefit plan. The appeal procedure described in section 62M.06 applies to any complaint as defined under section 62Q.68, subdivision 2, that requires a medical determination in its resolution.
(b) Effective January 1, 2026, this chapter applies to managed care plans or county-based purchasing plans when the plan is providing coverage to state public health care program enrollees under chapter 256B or 256L.
(c) Effective January 1, 2026, the following sections of this chapter apply to services delivered under chapters 256B and 256L: 62M.02, subdivisions 1 to 5, 7 to 12, 13, 14 to 18, and 21; 62M.04; 62M.05, subdivisions 1 to 4; 62M.06, subdivisions 1 to 3; 62M.07; 62M.072; 62M.09; 62M.10; 62M.12; 62M.17, subdivision 2; and 62M.18.
62M.03 COMPLIANCE WITH STANDARDS.
Beginning January 1, 1993, any organization that meets the definition of utilization review organization in section 62M.02, subdivision 21, must be licensed under chapter 60A, 62C, 62D, 62N, 62T, or 64B, or registered under this chapter and must comply with this chapter and section 72A.201, subdivisions 8 and 8a. Each licensed community integrated service network or health maintenance organization that has an employed staff model of providing health care services shall comply with this chapter and section 72A.201, subdivisions 8 and 8a, for any services provided by providers under contract.
An organization that meets the definition of a utilization review organization under section 62M.02, subdivision 21, that is not licensed in this state that performs utilization review services for Minnesota residents must register with the commissioner of commerce and must certify compliance with this chapter.
Initial registration must occur no later than January 1, 1993. The registration is effective for two years and may be renewed. Applications for initial and renewal registrations must be made on forms prescribed by the commissioner. Each utilization review organization registered under this chapter shall notify the commissioner of commerce within 30 days of any change in the name, address, or ownership of the organization. The organization shall pay to the commissioner of commerce a fee of $1,000 for the initial registration application and $1,000 for each two-year renewal.
If a utilization review organization fails to comply with this chapter, the organization may not provide utilization review services for any Minnesota resident. The commissioner of commerce may issue a cease and desist order under section 45.027, subdivision 5, to enforce this provision. The cease and desist order is subject to appeal under chapter 14. A nonlicensed utilization review organization that fails to comply with the provisions of this chapter is subject to all applicable penalty and enforcement provisions of section 72A.201. Each utilization review organization licensed under chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with this chapter as a condition of licensure.
62S.02 QUALIFIED LONG-TERM CARE INSURANCE POLICY.
A qualified long-term care insurance policy may not be offered, issued, delivered, or renewed in this state unless the policy satisfies the requirements of this chapter and the filing provisions of section 62A.02. A qualified long-term care insurance policy must cover qualified long-term care services.
An insurer shall offer a nonforfeiture provision available in the event of default in the payment of any premiums. The amount of the benefit may be adjusted after being initially granted, if necessary, to reflect changes in claims, persistency, and interest as reflected in changes in rates for premium paying contracts. The nonforfeiture provision must provide at least one of the following:
(1) reduced paid-up insurance;
(2) extended term insurance; or
(3) shortened benefit period.
A qualified long-term care insurance policy shall not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed. The aggregate premium paid under the policy may be refunded in the event of death of the insured or a complete surrender or cancellation of the policy.
A qualified long-term care insurance policy shall not pay or reimburse expenses incurred for services or items if the expenses are reimbursable under Medicare or would be reimbursable if a deductible or coinsurance amount was not applied. This subdivision does not apply to expenses which are reimbursable under Medicare only as a secondary payor and does not prohibit the offering of a qualified long-term care insurance policy on the basis that the policy coordinates its benefits with those provided under Medicare. Notwithstanding this subdivision, payments may be made under a long-term care insurance policy on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.
A qualified long-term care insurance policy shall take into account at least five of the activities of daily living in making the determination of whether an individual is chronically ill. Assessments of activities of daily living and cognitive impairment must be performed by a licensed or certified professional, such as a physician, physician assistant, nurse, or social worker.
A qualified long-term care insurance policy must include a clear description of the process for appealing and resolving benefit determinations.
62S.021 LONG-TERM CARE INSURANCE; INITIAL FILING.
This section applies to any long-term care policy issued in this state on or after January 1, 2002, under this chapter or sections 62A.46 to 62A.56.
An insurer shall provide the following information to the commissioner 30 days prior to making a long-term care insurance form available for sale:
(1) a copy of the disclosure documents required in section 62S.081; and
(2) an actuarial certification consisting of at least the following:
(i) a statement that the initial premium rate schedule is sufficient to cover anticipated costs under moderately adverse experience and that the premium rate schedule is reasonably expected to be sustainable over the life of the form with no future premium increases anticipated;
(ii) a statement that the policy design and coverage provided have been reviewed and taken into consideration;
(iii) a statement that the underwriting and claims adjudication processes have been reviewed and taken into consideration; and
(iv) a complete description of the basis for contract reserves that are anticipated to be held under the form, to include:
(A) sufficient detail or sample calculations provided so as to have a complete depiction of the reserve amounts to be held;
(B) a statement that the assumptions used for reserves contain reasonable margins for adverse experience;
(C) a statement that the net valuation premium for renewal years does not increase, except for attained age rating where permitted;
(D) a statement that the difference between the gross premium and the net valuation premium for renewal years is sufficient to cover expected renewal expenses, or if such a statement cannot be made, a complete description of the situations in which this does not occur. An aggregate distribution of anticipated issues may be used as long as the underlying gross premiums maintain a reasonably consistent relationship. If the gross premiums for certain age groups appear to be inconsistent with this requirement, the commissioner may request a demonstration under item (i) based on a standard age distribution; and
(E) either a statement that the premium rate schedule is not less than the premium rate schedule for existing similar policy forms also available from the insurer except for reasonable differences attributable to benefits, or a comparison of the premium schedules for similar policy forms that are currently available from the insurer with an explanation of the differences.
The commissioner may request an actuarial demonstration that benefits are reasonable in relation to premiums. The actuarial demonstration must include either premium and claim experience on similar policy forms, adjusted for any premium or benefit differences, relevant and credible data from other studies, or both. If the commissioner asks for additional information under this subdivision, the 30-day time limit in subdivision 2 does not include the time during which the insurer is preparing the requested information.
62M.072 USE OF EVIDENCE-BASED STANDARDS.
If no independently developed evidence-based standards exist for a particular treatment, testing, or imaging procedure, then an insurer or utilization review organization shall not deny coverage of the treatment, testing, or imaging based solely on the grounds that the treatment, testing, or imaging does not meet an evidence-based standard. This section does not prohibit an insurer or utilization review organization from denying coverage for services that are investigational, experimental, or not medically necessary.
62M.08 CONFIDENTIALITY.
A utilization review organization must have written procedures for ensuring that patient-specific information obtained during the process of utilization review will be:
(1) kept confidential in accordance with applicable federal and state laws;
(2) used solely for the purposes of utilization review, quality assurance, discharge planning, and case management; and
(3) shared only with those organizations or persons that have the authority to receive such information.
Summary data is not subject to this section if it does not provide sufficient information to allow identification of individual patients.
62S.03 EXTRATERRITORIAL JURISDICTION.
Group long-term care insurance coverage may not be offered to a resident of this state under a group policy issued in another state to a group described in section 62S.01, subdivision 15, clause (4), unless this state or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in this state has made a determination that the requirements have been met.
62Q.02 APPLICABILITY OF CHAPTER.
(a) This chapter applies only to health plans, as defined in section 62Q.01, and not to other types of insurance issued or renewed by health plan companies, unless otherwise specified.
(b) This chapter applies to a health plan company only with respect to health plans, as defined in section 62Q.01, issued or renewed by the health plan company, unless otherwise specified.
(c) If a health plan company issues or renews health plans in other states, this chapter applies only to health plans issued or renewed in this state for Minnesota residents, or to cover a resident of the state, unless otherwise specified.
62S.04 PROHIBITIONS.
A long-term care insurance policy may not:
(1) be canceled, nonrenewed, or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;
(2) contain a provision establishing a new waiting period in the event existing coverage is converted to or replaced by a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or
(3) provide coverage for skilled nursing care only, or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care in the same facility.
62Q.021 FEDERAL ACT; COMPLIANCE REQUIRED.
Each health plan company shall comply with the federal Health Insurance Portability and Accountability Act of 1996, including any federal regulations adopted under that act, to the extent that it imposes a requirement that applies in this state and that is not also required by the laws of this state. This section does not require compliance with any provision of the federal act prior to the effective date provided for that provision in the federal act. The commissioner shall enforce this subdivision.
Each health plan company shall comply with the Affordable Care Act to the extent that it imposes a requirement that applies in this state but is not required under the laws of this state. This section does not require compliance with any provision of the Affordable Care Act before the effective date provided for that provision in the Affordable Care Act. The commissioner shall enforce this subdivision.
Each health plan company, health provider, and health facility shall comply with the No Surprises Act, including any federal regulations adopted under the act, to the extent that the act imposes requirements that apply in this state but are not required under the laws of this state. This subdivision does not require compliance with any provision of the No Surprises Act before the effective date provided for that provision in the No Surprises Act. The commissioner shall enforce this subdivision.
62R.01 STATEMENT OF LEGISLATIVE PURPOSE AND INTENT.
The legislature finds that the goals of containing health care costs, improving the quality of health care, and increasing the access of Minnesota citizens to health care services reflected under chapters 62J and 62N may be further enhanced through the promotion of health care cooperatives. The legislature further finds that locally based and controlled efforts among health care providers, local businesses, units of local government, and health care consumers, can promote the attainment of the legislature's goals of health care reform, and takes notice of the long history of successful operations of cooperative organizations in this state. Therefore, in order to encourage cooperative efforts which are consistent with the goals of health care reform, including efforts among health care providers as sellers of health care services and efforts of consumers as buyers of health care services and health plan coverage, and to encourage the formation of and increase the competition among health plans in Minnesota, the legislature enacts the Minnesota Health Care Cooperative Act.
62S.05 PREEXISTING CONDITION.
A long-term care insurance policy or certificate, other than a policy or certificate issued to a group as defined in section 62S.01, subdivision 15, clause (1), may not use a definition of preexisting condition that is more restrictive than the definition in this subdivision. "Preexisting condition" means a condition for which medical advice or treatment was recommended by, or received from a provider of health care services, within six months before the effective date of coverage of an insured person.
A long-term care insurance policy or certificate, other than a policy or certificate issued to a group as defined in section 62S.01, subdivision 15, clause (1), may not exclude coverage for a loss or confinement that is the result of a preexisting condition more than six months following the effective date of coverage of an insured person.
The definition of preexisting condition does not prohibit an insurer from using an application form designed to elicit the complete health history of an applicant and, on the basis of the answers on that application, from underwriting according to that insurer's established underwriting standards. Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application, need not be covered until the waiting period described in subdivision 2 expires. A long-term care insurance policy or certificate may not exclude or use waivers of any kind to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subdivision 2.
The commissioner may extend the limitation periods set forth in subdivisions 1 and 2 as to specific age group categories in specific policy forms upon finding that the extension is in the best interest of the public.
62Q.025 HIGH DEDUCTIBLE HEALTH PLANS.
A high deductible health plan shall be deemed a qualified plan under sections 62E.06 and 62E.12. The plan must meet all other requirements of state law except those that are inconsistent with a high deductible health plan as defined in sections 220 and 223 of the Internal Revenue Code and supporting regulations.
Notwithstanding any other law of this state, any health plan company defined in section 62Q.01, subdivision 4, is permitted to offer high deductible health plans.
62R.02 CITATION.
This chapter may be cited as the "Minnesota Health Care Cooperative Act."
62M.11 COMPLAINTS TO COMMERCE OR HEALTH.
Notwithstanding the provisions of this chapter, an enrollee may file a complaint regarding an adverse determination directly to the commissioner responsible for regulating the utilization review organization.
62S.06 PRIOR HOSPITALIZATION OR INSTITUTIONALIZATION.
A long-term care insurance policy may not be delivered or issued for delivery in this state if the policy conditions eligibility for any benefits:
(1) on a prior hospitalization requirement;
(2) provided in an institutional care setting on the receipt of a higher level of institutional care; or
(3) other than waiver of premium, postconfinement, postacute care, or recuperative benefits on a prior institutionalization requirement.
A long-term care insurance policy containing postconfinement, postacute care, or recuperative benefits must clearly label in a separate paragraph of the policy or certificate entitled "limitations or conditions on eligibility for benefits" the limitations or conditions, including any required number of days of confinement.
(a) A long-term care insurance policy or rider that conditions eligibility of noninstitutional benefits on the prior receipt of institutional care may not require a prior institutional stay of more than 30 days.
(b) A long-term care insurance policy or rider that provides benefits only following institutionalization may not condition the benefits upon admission to a facility for the same or related conditions within a period of less than 30 days after discharge from the institution.
62R.03 APPLICABILITY OF OTHER LAWS.
A health care cooperative is subject to chapter 308A unless otherwise provided in this chapter. After incorporation, a health care cooperative shall enjoy the powers and privileges and shall be subject to the duties and liabilities of other cooperatives organized under chapter 308A, to the extent applicable and except as limited or enlarged by this chapter. If any provision of this chapter conflicts with a provision of chapter 308A, the provision of this chapter takes precedence.
A health care network cooperative must be licensed as a health maintenance organization licensed under chapter 62D, a nonprofit health service plan corporation licensed under chapter 62C, or a community integrated service network licensed under chapter 62N, at the election of the health care network cooperative. The health care network cooperative shall be subject to the duties and liabilities of health plans licensed pursuant to the chapter under which the cooperative elects to be licensed, to the extent applicable and except as limited or enlarged by this chapter. If any provision of any chapter under which the cooperative elects to be licensed conflicts with the provisions of this chapter, the provisions of this chapter take precedence. A health care network cooperative, upon licensure as provided in this subdivision, is a contributing member of the Minnesota Comprehensive Health Association, on the same basis as other entities having the same licensure.
A health provider cooperative shall not be considered a mutual insurance company under chapter 60A, a health maintenance organization under chapter 62D, a nonprofit health services corporation under chapter 62C, or a community integrated service network under chapter 62N. A health provider network shall not be considered to violate any limitations on the corporate practice of medicine. Health care service contracts under section 62R.06 shall not be considered to violate section 62J.23.
62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES.
No individual who is performing utilization review may receive any financial incentive based on the number of adverse determinations made by such individual, provided that utilization review organizations may establish medically appropriate performance standards. This prohibition does not apply to financial incentives established between health plan companies and providers.
62S.07 RIGHT TO RETURN; REFUND.
A long-term care insurance applicant may return the policy or certificate within 30 days of its delivery and is entitled to a refund of the premium if, after examination of the policy or certificate, the applicant is not satisfied for any reason. Long-term care insurance policies and certificates must include a notice prominently printed on the first page or attached to the first page stating in substance that the applicant may return the policy or certificate within 30 days of its delivery and have the premium refunded if for any reason, after examination of the policy or certificate, other than a certificate issued under a policy issued to a group as defined in section 62S.01, subdivision 15, clause (1), the applicant is not satisfied.
If an application for a qualified long-term care insurance policy is denied, the issuer shall refund to the applicant any premium and fees submitted by the applicant within 30 days of the denial.
62R.04 DEFINITIONS.
For purposes of this chapter, the terms defined in this section have the meanings given.
"Health care cooperative" means a health care network cooperative or a health provider cooperative.
"Health care network cooperative" means a corporation organized under this chapter and licensed in accordance with section 62R.03, subdivision 2. A health care network cooperative shall not have more than 50,000 enrollees, unless exceeding the enrollment limit is necessary to comply with guaranteed issue or guaranteed renewal requirements of chapter 62L or section 62A.65.
"Health provider cooperative" means a corporation organized under this chapter and operated on a cooperative plan to market health care services to purchasers of those services.
Unless otherwise specified, "commissioner" means the commissioner of health for a health care network cooperative licensed under chapter 62D or 62N and the commissioner of commerce for a health care network cooperative licensed under chapter 62C.
"Health carrier" has the meaning provided in section 62A.011.
"Health care providing entity" means a participating entity that provides health care to enrollees of a health care cooperative.
62M.13 SEVERABILITY.
If any provisions of this chapter are held invalid, illegal, or unenforceable for any reason and in any respect, the holding does not affect the validity of the remainder of this chapter.
62M.14 EFFECT OF COMPLIANCE.
Evidence of a utilization review organization's compliance or noncompliance with the provisions of this chapter shall not be determinative in an action alleging that services denied were medically necessary and covered under the terms of the enrollee's health benefit plan.
62R.05 POWERS.
In addition to the powers enumerated under section 308A.201, a health care cooperative shall have all of the powers granted a nonprofit corporation under section 317A.161, except to the extent expressly inconsistent with the provisions of chapter 308A.
62M.15 APPLICABILITY OF OTHER CHAPTER REQUIREMENTS.
The requirements of this chapter regarding the conduct of utilization review are in addition to any specific requirements contained in chapter 62A, 62C, 62D, 62Q, 62T, or 72A.
62R.06 HEALTH CARE SERVICE CONTRACTS.
A health provider cooperative and its licensed members may execute marketing and service contracts requiring the provider members to provide some or all of their health care services through the provider cooperative to the enrollees, members, subscribers, or insureds, of a health care network cooperative, community integrated service network, nonprofit health service plan, health maintenance organization, accident and health insurance company, or any other purchaser, including the state of Minnesota and its agencies, instruments, or units of local government. Each purchasing entity is authorized to execute contracts for the purchase of health care services from a health provider cooperative in accordance with this section. A contract between a provider cooperative and a purchaser may provide for payment by the purchaser to the health provider cooperative on a capitated or similar risk-sharing basis, by fee-for-service arrangements, or by other financial arrangements authorized under state law. Each contract between a provider cooperative and a purchaser shall be filed by the provider network cooperative with the commissioner of health and is subject to the provisions of section 62D.19.
A health care network cooperative may contract with any health provider cooperative and may contract with any other licensed health care provider to provide health care services for its enrollees.
Subject to section 62R.08, a health care provider cooperative is not a combination in restraint of trade, and any contracts or agreements between a health care provider cooperative and its members regarding the price the cooperative will charge to purchasers of its services, or regarding the prices the members will charge to the cooperative, or regarding the allocation of gains or losses among the members, or regarding the delivery, quality, allocation, or location of services to be provided, are not contracts that unreasonably restrain trade.
62M.16 RULEMAKING.
If it is determined that rules are reasonable and necessary to accomplish the purpose of this chapter, the rules must be adopted through a joint rulemaking process by both the Department of Commerce and the Department of Health.
62S.09 CERTIFICATE REQUIREMENTS.
A certificate issued under a group long-term care insurance policy delivered or issued for delivery in this state must include:
(1) a description of the principal benefits and coverage provided in the policy;
(2) a statement of the exclusions, reductions, and limitations contained in the policy; and
(3) a statement that the group master policy determines governing contractual provisions.
The issuer of a qualified long-term care insurance policy shall deliver to the applicant, policyholder, or certificate holder the contract or certificate no later than 30 days after the date of approval.
62R.07 RELICENSURE.
(a) A health care network cooperative licensed under chapter 62C or 62D may relinquish that license and be granted a new license as a community integrated service network under chapter 62N in accordance with this section, provided that the cooperative meets all requirements for licensure as a network under chapter 62N, to the extent not expressly inconsistent with the provisions of chapter 308A.
(b) The relicensure shall be effective at the time specified in the plan of relicensure, which must not be earlier than the date upon which the previous license is surrendered.
(c) Upon the relicensure of the cooperative as a community integrated service network:
(1) all existing group and individual enrollee benefit contracts in force on the effective date of the relicensure shall continue in effect and with the same terms and conditions, notwithstanding the cooperative's new licensure as a network, until the date of each contract's next renewal or amendment, but no later than one year from the date of the relicensure. At this time, each benefit contract then in force must be amended to comply with all statutory and regulatory requirements for network benefit contracts as of that date; and
(2) all contracts between the cooperative and any health care providing entity, including a health care provider cooperative, in force on the effective date of relicensure shall remain in effect under the cooperative's new licensure as a network until the date of the next renewal or amendment of that contract, but no later than one year from the date of relicensure.
(d) Except as otherwise provided in this section, nothing in the relicensure of a health care network cooperative shall in any way affect its corporate existence or any of its contracts, rights, privileges, immunities, powers or franchises, debts, duties or other obligations or liabilities.
62Q.096 CREDENTIALING OF PROVIDERS.
(a) If a health plan company has initially credentialed, as providers in its provider network, individual providers employed by or under contract with an entity that:
(1) is authorized to bill under section 256B.0625, subdivision 5;
(2) is a mental health clinic certified under section 245I.20;
(3) is designated an essential community provider under section 62Q.19; and
(4) is under contract with the health plan company to provide mental health services, the health plan company must continue to credential at least the same number of providers from that entity, as long as those providers meet the health plan company's credentialing standards.
(b) In order to ensure timely access by patients to mental health services, between July 1, 2023, and June 30, 2025, a health plan company must credential and enter into a contract for mental health services with any provider of mental health services that:
(1) meets the health plan company's credential requirements. For purposes of credentialing under this paragraph, a health plan company may waive credentialing requirements that are not directly related to quality of care in order to ensure patient access to providers from underserved communities or to providers in rural areas;
(2) seeks to receive a credential from the health plan company;
(3) agrees to the health plan company's contract terms. The contract shall include payment rates that are usual and customary for the services provided;
(4) is accepting new patients; and
(5) is not already under a contract with the health plan company under a separate tax identification number or, if already under a contract with the health plan company, has provided notice to the health plan company of termination of the existing contract.
(c) A health plan company shall not refuse to credential these providers on the grounds that their provider network has:
(1) a sufficient number of providers of that type, including but not limited to the provider types identified in paragraph (a); or
(2) a sufficient number of providers of mental health services in the aggregate.
62S.10 POLICY SUMMARY.
At the time of policy delivery, a policy summary must be delivered for an individual life insurance policy that provides long-term care benefits within the policy or by rider. In the case of direct response solicitations, the insurer must deliver the policy summary upon the applicant's request, but regardless of request, must make the delivery no later than at the time of policy delivery.
The summary must include the following information:
(1) an explanation of how the long-term care benefit interacts with other components of the policy, including deductions from death benefits;
(2) an illustration of the amount of benefits, the length of benefits, and the guaranteed lifetime benefits, if any, for each covered person;
(3) any exclusions, reductions, and limitations on benefits of long-term care; and
(4) a statement that any long-term care inflation protection option required by section 62S.23 is not available under this policy.
If applicable to the policy type, the summary must include the following information:
(1) a disclosure of the effects of exercising other rights under the policy;
(2) a disclosure of guarantees related to long-term care costs of insurance charges; and
(3) current and projected maximum lifetime benefits.
62R.08 PROHIBITED PRACTICES.
(a) It shall be unlawful for any person, company, or corporation, or any agent, officer, or employee thereof, to coerce or require any person to agree, either in writing or orally, not to join or become or remain a member of, any health care provider cooperative, as a condition of securing or retaining a contract for health care services with the person, firm, or corporation.
(b) It shall be unlawful for any person, company, or corporation, or any combination of persons, companies, or corporations, or any agents, officers, or employees thereof, to engage in any acts of coercion, intimidation, or boycott of, or any refusal to deal with, any health care providing entity arising from that entity's actual or potential participation in a health care network cooperative or health care provider cooperative.
(c) It shall be unlawful for any health care network cooperative, other than a health care network cooperative operating on an employed, staff model basis, to require that its participating providers provide health care services exclusively to or through the health care network cooperative. It shall be unlawful for any health care provider cooperative to require that its members provide health care services exclusively to or through the health care provider cooperative.
(d) It shall be unlawful for any health care provider cooperative to engage in any acts of coercion, intimidation, or boycott of, or any concerted refusal to deal with, any health plan company seeking to contract with the cooperative on a competitive, reasonable, and nonexclusive basis.
(e) The prohibitions in this section are in addition to any conduct that violates sections 325D.49 to 325D.66.
(f) This section shall be enforced in accordance with sections 325D.56 to 325D.65.
62Q.097 REQUIREMENTS FOR TIMELY PROVIDER CREDENTIALING.
(a) The definitions in this subdivision apply to this section.
(b) "Clean application for provider credentialing" or "clean application" means an application for provider credentialing submitted by a health care provider to a health plan company that is complete, is in the format required by the health plan company, and includes all information and substantiation required by the health plan company and does not require evaluation of any identified potential quality or safety concern.
(c) "Provider credentialing" means the process undertaken by a health plan company to evaluate and approve a health care provider's education, training, residency, licenses, certifications, and history of significant quality or safety concerns in order to approve the health care provider to provide health care services to patients at a clinic or facility.
A health plan company that receives an application for provider credentialing must:
(1) if the application is determined to be a clean application for provider credentialing and if the health care provider submitting the application or the clinic or facility at which the health care provider provides services requests the information, affirm that the health care provider's application is a clean application and notify the health care provider or clinic or facility of the date by which the health plan company will make a determination on the health care provider's application;
(2) if the application is determined not to be a clean application, inform the health care provider of the application's deficiencies or missing information or substantiation within three business days after the health plan company determines the application is not a clean application; and
(3) make a determination on the health care provider's clean application within 45 days after receiving the clean application unless the health plan company identifies a substantive quality or safety concern in the course of provider credentialing that requires further investigation. Upon notice to the health care provider, clinic, or facility, the health plan company is allowed 30 additional days to investigate any quality or safety concerns.
An application for provider credentialing must not:
(1) require the provider to disclose past health conditions;
(2) require the provider to disclose current health conditions, if the provider is being treated so that the condition does not affect the provider's ability to practice medicine; or
(3) require the disclosure of any health conditions that would not affect the provider's ability to practice medicine in a competent, safe, and ethical manner.
62M.18 ANNUAL POSTING ON WEBSITE; PRIOR AUTHORIZATIONS.
(a) By April 1, 2022, and each April 1 thereafter, a health plan company must post on the health plan company's public website the following data for the immediately preceding calendar year for each commercial product:
(1) the number of prior authorization requests for which an authorization was issued;
(2) the number of prior authorization requests for which an adverse determination was issued and sorted by: (i) health care service; (ii) whether the adverse determination was appealed; and (iii) whether the adverse determination was upheld or reversed on appeal;
(3) the number of prior authorization requests that were submitted electronically and not by facsimile or email or other method pursuant to section 62J.497; and
(4) the reasons for prior authorization denial including but not limited to:
(i) patient did not meet prior authorization criteria;
(ii) incomplete information submitted by the provider to the utilization review organization;
(iii) change in treatment program; and
(iv) the patient is no longer covered by the plan.
(b) All information posted under this section must be written in easily understandable language.
62S.11 MONTHLY REPORT.
Any time a long-term care benefit, funded through a life insurance vehicle by the acceleration of the death benefit, is in benefit payment status, a monthly report must be provided to the policyholder.
The report must include the following information:
(1) long-term care benefits paid out during the month;
(2) an explanation of changes in the policy, such as death benefits or cash values, due to long-term care benefits being paid out; and
(3) the amount of long-term care benefits existing or remaining.
62N.22 DISCLOSURE OF COMMISSIONS.
Before selling any coverage or enrollment in a community integrated service network, a person selling the coverage or enrollment shall disclose in writing to the prospective purchaser the amount of any commission or other compensation the person will receive as a direct result of the sale. The disclosure may be expressed in dollars or as a percentage of the premium. The amount disclosed need not include any anticipated renewal commissions.
62S.12 CLAIM DENIAL.
If a claim under a qualified long-term care insurance contract is denied, the issuer shall provide a written explanation of the reasons for the denial and make available all information directly related to the denial within 60 days of the date of a written request by the policyholder or certificate holder, or a representative of the policyholder or certificate holder.
62M.19 ANNUAL REPORT TO COMMISSIONER OF HEALTH; PRIOR AUTHORIZATIONS.
On or before September 1 each year, each utilization review organization must report to the commissioner of health, in a form and manner specified by the commissioner, information on prior authorization requests for the previous calendar year. The report submitted under this subdivision must include the following data:
(1) the total number of prior authorization requests received;
(2) the number of prior authorization requests for which an authorization was issued;
(3) the number of prior authorization requests for which an adverse determination was issued;
(4) the number of adverse determinations reversed on appeal;
(5) the 25 codes with the highest number of prior authorization requests and the percentage of authorizations for each of these codes;
(6) the 25 codes with the highest percentage of prior authorization requests for which an authorization was issued and the total number of the requests;
(7) the 25 codes with the highest percentage of prior authorization requests for which an adverse determination was issued but which was reversed on appeal and the total number of the requests;
(8) the 25 codes with the highest percentage of prior authorization requests for which an adverse determination was issued and the total number of the requests; and
(9) the reasons an adverse determination to a prior authorization request was issued, expressed as a percentage of all adverse determinations. The reasons listed may include but are not limited to:
(i) the patient did not meet prior authorization criteria;
(ii) incomplete information was submitted by the provider to the utilization review organization;
(iii) the treatment program changed; and
(iv) the patient is no longer covered by the health benefit plan.
62Q.101 EVALUATION OF PROVIDER PERFORMANCE.
A health plan company, or a vendor of risk management services as defined under section 60A.23, subdivision 8, shall, in evaluating the performance of a health care provider:
(1) conduct the evaluation using a bona fide baseline based upon practice experience of the provider group; and
(2) disclose the baseline to the health care provider in writing and prior to the beginning of the time period used for the evaluation.
62S.13 INCONTESTABILITY PERIOD.
For a policy or certificate that has been in force for less than six months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to acceptance for coverage.
For a policy or certificate that has been in force for at least six months, but less than two years, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is both material to the acceptance for coverage and that pertains to the condition for which benefits are sought.
After a policy or certificate has been in force for two years, it is not contestable upon the grounds of misrepresentation alone. The policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured's health.
A long-term care insurance policy or certificate may not be field issued based on medical or health status. For purposes of this section, "field issued" means a policy or certificate issued by an agent or a third-party administrator under the underwriting authority granted to the agent or third-party administrator by an insurer and using the insurer's underwriting guidelines.
If an insurer has paid benefits under the long-term care insurance policy or certificate, the benefit payments may not be recovered by the insurer in the event that the policy or certificate is rescinded.
In the event of the death of the insured, this section shall not apply to the remaining death benefit of a life insurance policy that accelerates benefits for long-term care. In this situation, the remaining death benefits under these policies shall be governed by section 61A.03, subdivision 1, paragraph (c). In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care.