reglab/statecodes huggingface dataset:
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.481 — Cost-sharing For Prescription Drugs And Related Medical Supplies To Treat Chronic Disease.

62Q.481 COST-SHARING FOR PRESCRIPTION DRUGS AND RELATED MEDICAL SUPPLIES TO TREAT CHRONIC DISEASE.
Subdivision 1.
Cost-sharing limits.
(a) A health plan must limit the amount of any enrollee cost-sharing for prescription drugs prescribed to treat a chronic disease to no more than: (1) $25 per one-month supply for each prescription drug, regardless of the amount or type of medication required to fill the prescription; and (2) $50 per month in total for all related medical supplies. The cost-sharing limit for related medical supplies does not increase with the number of chronic diseases for which an enrollee is treated. Coverage under this section shall not be subject to any deductible.
(b) If application of this section before an enrollee has met the enrollee's plan deductible results in: (1) health savings account ineligibility under United States Code, title 26, section 223; or (2) catastrophic health plan ineligibility under United States Code, title 42, section 18022(e), this section applies to the specific prescription drug or related medical supply only after the enrollee has met the enrollee's plan deductible.
Subd. 2.
Definitions.
(a) For purposes of this section, the following definitions apply.
(b) "Chronic disease" means diabetes, asthma, and allergies requiring the use of epinephrine auto-injectors.
(c) "Cost-sharing" means co-payments and coinsurance.
(d) "Related medical supplies" means syringes, insulin pens, insulin pumps, test strips, glucometers, continuous glucose monitors, epinephrine auto-injectors, asthma inhalers, and other medical supply items necessary to effectively and appropriately treat a chronic disease or administer a prescription drug prescribed to treat a chronic disease.
History:
2023 c 57 art 2 s 46
NOTE:
This section, as added by Laws 2023, chapter 57, article 2, section 46, is effective January 1, 2025, and applies to health plans offered, issued, or renewed on or after that date. Laws 2023, chapter 57, article 2, section 46, the effective date.
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.49 — Enrollee Cost Sharing; Negotiated Provider Payments.

62Q.49 ENROLLEE COST SHARING; NEGOTIATED PROVIDER PAYMENTS.
Subdivision 1.
Applicability.
This section applies to all health plans, as defined in section 62Q.01, subdivision 3, that provide coverage for health care to be provided entirely or partially:
(1) through contracts in which health care providers agree to accept discounted charges, negotiated charges, or other limits on health care provider charges;
(2) by employees of, or facilities or entities owned by, the issuer of the health plan; or
(3) through contracts with health care providers that provide for payment to the providers on a fully or partially capitated basis or on any other non-fee-for-service basis.
Subd. 2.
Disclosure required.
(a) All health plans included in subdivision 1 must clearly specify how the cost of health care used to calculate any co-payments, coinsurance, or lifetime benefits will be affected by the arrangements described in subdivision 1.
(b) Any summary or other marketing material used in connection with marketing of a health plan that is subject to this section must prominently disclose and clearly explain the provisions required under paragraph (a), if the summary or other marketing material refers to co-payments, coinsurance, or maximum lifetime benefits.
(c) A health plan that is subject to paragraph (a) must not be used in this state if the commissioner of commerce or health, as appropriate, has determined that it does not comply with this section.
History:
1996 c 446 art 1 s 50
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.50 — Prostate Cancer Screening.

62Q.50 PROSTATE CANCER SCREENING.
A health plan must cover prostate cancer screening for men 40 years of age or over who are symptomatic or in a high-risk category and for all men 50 years of age or older.
The screening must consist at a minimum of a prostate-specific antigen blood test and a digital rectal examination.
This coverage is subject to any deductible, coinsurance, co-payment, or other limitation on coverage applicable to other coverages under the plan.
For purposes of this section, "health plan" includes coverage that is excluded under section 62A.011, subdivision 3, clauses (7) and (10).
History:
1996 c 446 art 1 s 51,72,73; 1998 c 339 s 12
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.51 — Point-of-service Option.

62Q.51 POINT-OF-SERVICE OPTION.
Subdivision 1.
Definition.
For purposes for this section, "point-of-service option" means a health plan under which the health plan company will reimburse an appropriately licensed or registered provider for providing covered services to an enrollee, without regard to whether the provider belongs to a particular network and without regard to whether the enrollee was referred to the provider by another provider.
Subd. 2.
Required point-of-service option.
Each health plan company operating in the small group or large group market shall offer at least one point-of-service option in each such market in which it operates.
Subd. 3.
Rate approval.
The premium rates and cost sharing requirements for each option must be submitted to the commissioner of health or the commissioner of commerce as required by law. A health plan that includes lower enrollee cost sharing for services provided by network providers than for services provided by out-of-network providers, or lower enrollee cost sharing for services provided with prior authorization or second opinion than for services provided without prior authorization or second opinion, qualifies as a point-of-service option.
Subd. 4.
Exemption.
This section does not apply to a health plan company with fewer than 50,000 enrollees in its commercial health plan products.
History:
1996 c 446 art 1 s 52; 1999 c 181 s 6
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.52 — Direct Access To Obstetric And Gynecologic Services.

62Q.52 DIRECT ACCESS TO OBSTETRIC AND GYNECOLOGIC SERVICES.
Subdivision 1.
Direct access.
(a) Health plan companies shall allow female enrollees direct access to providers who specialize in obstetrics and gynecology for the following services:
(1) evaluation and necessary treatment for obstetric conditions or emergencies;
(2) maternity care; and
(3) evaluation and necessary treatment for gynecologic conditions or emergencies, including annual preventive health examinations.
(b) For purposes of this section, "direct access" means that a female enrollee may obtain the obstetric and gynecologic services specified in paragraph (a) from providers who specialize in obstetrics and gynecology in the enrollee's network without a referral from, or prior approval through a primary care provider, another physician, the health plan company, or its representatives.
(c) The health plan company shall treat the provision of obstetrical and gynecological care and the ordering of related obstetrical and gynecological items and services, pursuant to paragraph (a), by a participating health care provider who specializes in obstetrics or gynecology as the authorization of a primary care provider.
(d) The health plan company may require the health care provider to agree to otherwise adhere to the health plan company's policies and procedures, including procedures for obtaining prior authorization and for providing services in accordance with a treatment plan, if any, approved by the health plan company.
(e) Health plan companies shall not require higher co-payments, coinsurance, deductibles, or other enrollee cost-sharing for direct access.
(f) This section applies only to services described in paragraph (a) that are covered by the enrollee's coverage, but coverage of a preventive health examination for female enrollees must not exclude coverage of a gynecologic examination.
(g) For purposes of this section, a health care provider who specializes in obstetrics or gynecology means any individual, including an individual other than a physician, who is authorized under state law to provide obstetrical or gynecological care.
(h) This section does not:
(1) waive any exclusions of coverage under the terms and conditions of the health plan with respect to coverage of obstetrical or gynecological care; or
(2) preclude the health plan company from requiring that the participating health care provider providing obstetrical or gynecological care notify the primary care provider or the health plan company of treatment decisions.
Subd. 2.
Notice.
A health plan company shall provide notice to enrollees of the provisions of subdivision 1 in accordance with the requirements of the Affordable Care Act.
Subd. 3.
Enforcement.
The commissioner of health shall enforce this section.
History:
1997 c 26 s 1; 2013 c 84 art 1 s 76
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.521 — Postnatal Care.

62Q.521 POSTNATAL CARE.
(a) For purposes of this section, "comprehensive postnatal visit" means a visit with a health care provider that includes a full assessment of the mother's and infant's physical, social, and psychological well-being, including but not limited to: mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance.
(b) A health plan must provide coverage for the following:
(1) a comprehensive postnatal visit with a health care provider not more than three weeks from the date of delivery;
(2) any postnatal visits recommended by a health care provider between three and 11 weeks from the date of delivery; and
(3) a comprehensive postnatal visit with a health care provider 12 weeks from the date of delivery.
(c) The requirements of this section are separate from and cannot be met by a visit made pursuant to section 62A.0411.
History:
2022 c 44 s 3
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.523 — Coverage For Prescription Contraceptives; Supply Requirements.

62Q.523 COVERAGE FOR PRESCRIPTION CONTRACEPTIVES; SUPPLY REQUIREMENTS.
Subdivision 1.
Scope of coverage.
Except as otherwise provided in section 62Q.522, subdivisions 3 and 4, all health plans that provide prescription coverage must comply with the requirements of this section.
Subd. 2.
Definition.
For purposes of this section, "prescription contraceptive" means any drug or device that requires a prescription and is approved by the Food and Drug Administration to prevent pregnancy. Prescription contraceptive does not include an emergency contraceptive drug that prevents pregnancy when administered after sexual contact.
Subd. 3.
Required coverage.
Health plan coverage for a prescription contraceptive must provide a 12-month supply for any prescription contraceptive if a 12-month supply is prescribed by the prescribing health care provider. The prescribing health care provider must determine the appropriate duration to prescribe the prescription contraceptives for up to 12 months.
History:
2023 c 70 art 2 s 28
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.528 — Drug Coverage In Emergency Situations.

62Q.528 DRUG COVERAGE IN EMERGENCY SITUATIONS.
A health plan that provides prescription drug coverage must provide coverage for a prescription drug dispensed by a pharmacist under section 151.211, subdivision 3, under the terms of coverage that would apply had the prescription drug been dispensed according to a prescription.
History:
1Sp2019 c 9 art 9 s 2
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.529 — Coverage For Drugs Prescribed And Dispensed By Pharmacies.

62Q.529 COVERAGE FOR DRUGS PRESCRIBED AND DISPENSED BY PHARMACIES.
(a) A health plan that provides prescription coverage must provide coverage for self-administered hormonal contraceptives, nicotine replacement medications, and opiate antagonists for the treatment of an acute opiate overdose prescribed and dispensed by a licensed pharmacist in accordance with section 151.37, subdivision 14, 15, or 16, under the same terms of coverage that would apply had the prescription drug been prescribed by a licensed physician, physician assistant, or advanced practice registered nurse.
(b) A health plan is not required to cover the drug if dispensed by an out-of-network pharmacy, unless the health plan covers prescription drugs dispensed by out-of-network pharmacies.
History:
2020 c 115 art 2 s 2; 2022 c 58 s 170
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.53 — Mental Health Coverage; Medically Necessary Care.

62Q.53 MENTAL HEALTH COVERAGE; MEDICALLY NECESSARY CARE.
Subdivision 1.
Requirement.
No health plan that covers mental health services may be offered, sold, issued, or renewed in this state that requires mental health services to satisfy a definition of "medically necessary care," "medical necessity," or similar term that is more restrictive with respect to mental health than the definition provided in subdivision 2.
Subd. 2.
Minimum definition.
"Medically necessary care" means health care services appropriate, in terms of type, frequency, level, setting, and duration, to the enrollee's diagnosis or condition, and diagnostic testing and preventive services. Medically necessary care must be consistent with generally accepted practice parameters as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure, or treatment at issue and must:
(1) help restore or maintain the enrollee's health; or
(2) prevent deterioration of the enrollee's condition.
Subd. 3.
Health plan; definition.
For purposes of this section, "health plan" has the meaning given in section 62Q.01, subdivision 3, but includes the coverages listed in section 62A.011, subdivision 3, clauses (7) and (10).
History:
1997 c 49 s 1
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.535 — Coverage For Court-ordered Mental Health Services.

62Q.535 COVERAGE FOR COURT-ORDERED MENTAL HEALTH SERVICES.
Subdivision 1.
Mental health services.
For purposes of this section, mental health services means all covered services that are intended to treat or ameliorate an emotional, behavioral, or psychiatric condition and that are covered by the policy, contract, or certificate of coverage of the enrollee's health plan company or by law.
Subd. 2.
Coverage required.
(a) All health plan companies that provide coverage for mental health services must cover or provide mental health services ordered by a court of competent jurisdiction under a court order that is issued on the basis of a behavioral care evaluation performed by a licensed psychiatrist or a doctoral level licensed psychologist, which includes a diagnosis and an individual treatment plan for care in the most appropriate, least restrictive environment. The health plan company must be given a copy of the court order and the behavioral care evaluation. The health plan company shall be financially liable for the evaluation if performed by a participating provider of the health plan company and shall be financially liable for the care included in the court-ordered individual treatment plan if the care is covered by the health plan and ordered to be provided by a participating provider or another provider as required by rule or law. This court-ordered coverage must not be subject to a separate medical necessity determination by a health plan company under its utilization procedures.
(b) A party or interested person, including a health plan company or its designee, may make a motion for modification of the court-ordered plan of care pursuant to the applicable rules of procedure for modification of the court's order. The motion may include a request for a new behavioral care evaluation according to this section.
History:
1Sp2001 c 9 art 9 s 3; 2002 c 379 art 1 s 113
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.54 — Referrals For Residents Of Health Care Facilities.

62Q.54 REFERRALS FOR RESIDENTS OF HEALTH CARE FACILITIES.
If an enrollee is a resident of a health care facility licensed under chapter 144A or an assisted living facility licensed under chapter 144G, the enrollee's primary care provider must refer the enrollee to that facility's skilled nursing unit or that facility's appropriate care setting, provided that the health plan company and the provider can best meet the patient's needs in that setting, if the following conditions are met:
(1) the facility agrees to be reimbursed at that health plan company's contract rate negotiated with similar providers for the same services and supplies; and
(2) the facility meets all guidelines established by the health plan company related to quality of care, utilization, referral authorization, risk assumption, use of health plan company network, and other criteria applicable to providers under contract for the same services and supplies.
History:
1997 c 225 art 2 s 45; 2020 c 115 art 4 s 11; 7Sp2020 c 1 art 6 s 25
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.545 — Coverage Of Home Care Nursing.

62Q.545 COVERAGE OF HOME CARE NURSING.
(a) Home care nursing services, as provided under section 256B.0625, subdivision 7, with the exception of section 256B.0654, subdivision 4, shall be covered under a health plan for persons who are concurrently covered by both the health plan and enrolled in medical assistance under chapter 256B.
(b) For purposes of this section, a period of home care nursing services may be subject to the co-payment, coinsurance, deductible, or other enrollee cost-sharing requirements that apply under the health plan. Cost-sharing requirements for home care nursing services must not place a greater financial burden on the insured or enrollee than those requirements applied by the health plan to other similar services or benefits. Nothing in this section is intended to prevent a health plan company from requiring prior authorization by the health plan company for such services as required by section 256B.0625, subdivision 7, or use of contracted providers under the applicable provisions of the health plan.
History:
1Sp2010 c 1 art 19 s 1; 2014 c 291 art 9 s 5
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.57 — Designation Of Primary Care Provider.

62Q.57 DESIGNATION OF PRIMARY CARE PROVIDER.
Subdivision 1.
Choice of primary care provider.
(a) If a health plan company offering a group health plan, or an individual health plan that is not a grandfathered plan, requires or provides for the designation by an enrollee of a participating primary care provider, the health plan company shall permit each enrollee to:
(1) designate any participating primary care provider available to accept the enrollee; and
(2) for a child, designate any participating physician, advanced practice registered nurse, or physician assistant who specializes in pediatrics as the child's primary care provider and is available to accept the child.
(b) This section does not waive any exclusions of coverage under the terms and conditions of the health plan with respect to coverage of pediatric care.
Subd. 2.
Notice.
A health plan company shall provide notice to enrollees of the provisions of subdivision 1 in accordance with the requirements of the Affordable Care Act.
Subd. 3.
Enforcement.
The commissioner shall enforce this section.
History:
2013 c 84 art 1 s 79; 2020 c 115 art 4 s 12; 2022 c 58 s 12
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.645 — Efficiency Reports And Distribution Of Information.

62Q.645 EFFICIENCY REPORTS AND DISTRIBUTION OF INFORMATION.
(a) The commissioner may use reports submitted by health plan companies, service cooperatives, and the public employee insurance program created in section 43A.316 to compile entity specific administrative efficiency reports; may make these reports available on state agency websites, including minnesotahealthinfo.com; and may include information on:
(1) number of covered lives;
(2) covered services;
(3) geographic availability;
(4) whom to contact to obtain current premium rates;
(5) administrative costs, using the definition of administrative costs developed under section 62J.38;
(6) Internet links to information on the health plan, if available; and
(7) any other information about the health plan identified by the commissioner as being useful for employers, consumers, providers, and others in evaluating health plan options.
(b) This section does not apply to a health plan company unless its annual Minnesota premiums exceed $50,000,000 based on the most recent assessment base of the Minnesota Comprehensive Health Association. For purposes of this determination, the premiums of a health plan company include those of its affiliates.
History:
2006 c 255 s 34
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.65 — Access To Provider Discounts.

62Q.65 ACCESS TO PROVIDER DISCOUNTS.
Subdivision 1.
Requirement.
A high deductible health plan must, when used in connection with a medical savings account or health savings account, provide the enrollee access to any discounted provider fees for services covered by the high deductible health plan, regardless of whether the enrollee has satisfied the deductible for the high deductible health plan.
Subd. 2.
Definitions.
For purposes of this section, the following terms have the meanings given:
(1) "high deductible health plan" has the meaning given under the Internal Revenue Code of 1986, section 220(c)(2), with respect to a medical savings account; and the meaning given under Internal Revenue Code of 1986, section 223(c)(2), with respect to a health savings account;
(2) "medical savings account" has the meaning given under the Internal Revenue Code of 1986, section 220(d)(1);
(3) "discounted provider fees" means fees contained in a provider agreement entered into by the issuer of the high deductible health plan, or an affiliate of the issuer, for use in connection with the high deductible health plan; and
(4) "health savings account" has the meaning given under the Internal Revenue Code of 1986, section 223(d).
History:
1997 c 225 art 2 s 46; 2005 c 132 s 17
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.66 — Durable Medical Equipment Coverage.

62Q.66 DURABLE MEDICAL EQUIPMENT COVERAGE.
No health plan company that covers durable medical equipment may utilize medical coverage criteria for durable medical equipment that limits coverage solely to equipment used in the home.
History:
1998 c 334 s 1
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.67 — Disclosure Of Covered Durable Medical Equipment.

62Q.67 DISCLOSURE OF COVERED DURABLE MEDICAL EQUIPMENT.
Subdivision 1.
Disclosure.
A health plan company that covers durable medical equipment shall provide enrollees, and upon request prospective enrollees, written disclosure that includes the information set forth in subdivision 2. The health plan company may include the information in the member contract, certificate of coverage, schedule of payments, member handbook, or other written enrollee communication.
Subd. 2.
Information to be disclosed.
A health plan company that covers durable medical equipment shall disclose the following information:
(1) general descriptions of the coverage for durable medical equipment, level of coverage available, and criteria and procedures for any required prior authorizations; and
(2) the address and telephone number of a health plan representative whom an enrollee may contact to obtain specific information verbally, or upon request in writing, about prior authorization including criteria used in making coverage decisions and information on limitations or exclusions for durable medical equipment.
History:
1998 c 334 s 2
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.675 — Hearing Aids.

62Q.675 HEARING AIDS.
A health plan must cover hearing aids for all individuals for hearing loss that is not correctable by other covered procedures. Coverage required under this section is limited to one hearing aid in each ear every three years. No special deductible, coinsurance, co-payment, or other limitation on the coverage under this section that is not generally applicable to other coverages under the plan may be imposed.
History:
1Sp2003 c 14 art 7 s 24; 2007 c 60 s 1; 2023 c 70 art 3 s 2
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.676 — Medication Therapy Management.

62Q.676 MEDICATION THERAPY MANAGEMENT.
A pharmacy benefit manager that provides prescription drug services must make available medication therapy management services for enrollees taking four or more prescriptions to treat or prevent two or more chronic medical conditions. For purposes of this section, "medication therapy management" means the provision of the following pharmaceutical care services by, or under the supervision of, a licensed pharmacist to optimize the therapeutic outcomes of the patient's medications:
(1) performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events;
(2) communicating essential information to the patient's other primary care providers; and
(3) providing verbal education and training designed to enhance patient understanding and appropriate use of the patient's medications.
Nothing in this section shall be construed to expand or modify the scope of practice of the pharmacist as defined in section 151.01, subdivision 27.
History:
2009 c 79 art 4 s 7
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.678 — Dependent Child Notice.

62Q.678 DEPENDENT CHILD NOTICE.
Group health plans and health plan companies that offer group or individual health plans with dependent coverage must provide written notice to an enrollee with dependent child coverage that the dependent child's coverage ends when the child reaches the age of 26. Notice must be sent to the enrollee at the enrollee's last known address at least 60 days before the dependent child reaches the age of 26. The notice must include the date on which coverage ends and information on accessing the MNsure website as applicable.
History:
2020 c 73 s 2
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.68 — Definitions.

62Q.68 DEFINITIONS.
Subdivision 1.
Application.
For purposes of sections 62Q.68 to 62Q.72, the terms defined in this section have the meanings given them. For purposes of sections 62Q.69 and 62Q.70, the term "health plan company" does not include an insurance company licensed under chapter 60A to offer, sell, or issue a policy of accident and sickness insurance as defined in section 62A.01 or a nonprofit health service plan corporation regulated under chapter 62C that only provides dental coverage or vision coverage. For purposes of sections 62Q.69 through 62Q.73, the term "health plan company" does not include the Comprehensive Health Association created under chapter 62E. Section 62Q.70 does not apply to individual coverage. However, a health plan company offering individual coverage may, pursuant to section 62Q.69, subdivision 3, paragraph (c), follow the process outlined in section 62Q.70.
Subd. 2.
Complaint.
"Complaint" means any grievance against a health plan company that is not the subject of litigation and that has been submitted by a complainant to a health plan company regarding the provision of health services including, but not limited to, the scope of coverage for health care services; retrospective denials or limitations of payment for services; eligibility issues; denials, cancellations, or nonrenewals of coverage; administrative operations; and the quality, timeliness, and appropriateness of health care services rendered. If the complaint is from an applicant, the complaint must relate to the application. If the complaint is from a former enrollee, the complaint must relate to services received during the period of time the individual was an enrollee. Any grievance requiring a medical determination in its resolution must have the medical determination aspect of the complaint processed under the appeal procedure described in section 62M.06.
Subd. 3.
Complainant.
"Complainant" means an enrollee, applicant, or former enrollee, or anyone acting on behalf of an enrollee, applicant, or former enrollee, who submits a complaint.
History:
1999 c 239 s 34; 2002 c 330 s 28; 2013 c 84 art 1 s 81
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.70 — Appeal Of The Complaint Decision.

62Q.70 APPEAL OF THE COMPLAINT DECISION.
Subdivision 1.
Establishment.
(a) Each health plan company shall establish an internal appeal process for reviewing a health plan company's decision regarding a complaint filed in accordance with section 62Q.69. The appeal process must meet the requirements of this section. This section applies only to group health plans. However, a health plan company offering individual coverage may, pursuant to section 62Q.69, subdivision 3, paragraph (c), follow the process outlined in this section.
(b) The person or persons with authority to resolve or recommend the resolution of the internal appeal must not be solely the same person or persons who made the complaint decision under section 62Q.69.
(c) The internal appeal process must permit the enrollee to review the information relied upon in the course of the appeal and the receipt of testimony, correspondence, explanations, or other information from the complainant, staff persons, administrators, providers, or other persons as deemed necessary by the person or persons investigating or presiding over the appeal.
(d) The enrollee must be allowed to receive continued coverage pending the outcome of the appeals process.
Subd. 2.
Procedures for filing an appeal.
The health plan company must provide notice to enrollees of its internal appeals process in a culturally and linguistically appropriate manner consistent with the provisions of the Affordable Care Act. If a complainant notifies the health plan company of the complainant's desire to appeal the health plan company's decision regarding the complaint through the internal appeal process, the health plan company must provide the complainant the option for the appeal to occur either in writing or by hearing.
Subd. 3.
Notification of appeal decisions.
(a) If a complainant appeals in writing, the health plan company must give the complainant written notice of the appeal decision and all key findings within 30 days of the health plan company's receipt of the complainant's written notice of appeal. If a complainant appeals by hearing, the health plan company must give the complainant written notice of the appeal decision and all key findings within 45 days of the health plan company's receipt of the complainant's written notice of appeal.
(b) If the appeal decision is partially or wholly adverse to the complainant, the notice must advise the complainant of the right to submit the appeal decision to the external review process described in section 62Q.73 and the procedure for initiating the external process.
(c) Upon the request of the complainant, the health plan company must provide the complainant with a complete summary of the appeal decision.
History:
1999 c 239 s 36; 2013 c 84 art 1 s 83,84
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.71 — Notice To Enrollees.

62Q.71 NOTICE TO ENROLLEES.
Each health plan company shall provide to enrollees a clear and concise description of its complaint resolution procedure, if applicable under section 62Q.68, subdivision 1, and the procedure used for utilization review as defined under chapter 62M as part of the member handbook, subscriber contract, or certificate of coverage. If the health plan company does not issue a member handbook, the health plan company may provide the description in another written document. The description must specifically inform enrollees:
(1) how to submit a complaint to the health plan company;
(2) if the health plan includes utilization review requirements, how to notify the utilization review organization in a timely manner and how to obtain authorization for health care services;
(3) how to request an appeal either through the procedures described in section 62Q.70, if applicable, or through the procedures described in chapter 62M;
(4) of the right to file a complaint with either the commissioner of health or commerce at any time during the complaint and appeal process;
(5) of the toll-free telephone number of the appropriate commissioner; and
(6) of the right, for individual and group coverage, to obtain an external review under section 62Q.73 and a description of when and how that right may be exercised, including that under most circumstances an enrollee must exhaust the internal complaint or appeal process prior to external review. However, an enrollee may proceed to external review without exhausting the internal complaint or appeal process under the following circumstances:
(i) the health plan company waives the exhaustion requirement;
(ii) the health plan company is considered to have waived the exhaustion requirement by failing to substantially comply with any requirements including, but not limited to, time limits for internal complaints or appeals; or
(iii) the enrollee has applied for an expedited external review at the same time the enrollee has applied for internal review under chapter 62M.
History:
1999 c 239 s 37; 2003 c 2 art 1 s 8; 2013 c 84 art 1 s 85; 2020 c 114 art 2 s 17
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.72 — Record Keeping; Reporting.

62Q.72 RECORD KEEPING; REPORTING.
Subdivision 1.
Record keeping.
Each health plan company shall maintain records of all enrollee complaints and their resolutions. These records shall be retained for five years and shall be made available to the appropriate commissioner upon request. An insurance company licensed under chapter 60A may instead comply with section 72A.20, subdivision 30.
Subd. 2.
Reporting.
Each health plan company shall submit to the appropriate commissioner, as part of the company's annual filing, data on the number and type of complaints that are not resolved within 30 days, or 30 business days as provided under section 72A.201, subdivision 4, clause (3), for insurance companies licensed under chapter 60A. The commissioner shall also make this information available to the public upon request.
History:
1999 c 239 s 38
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.731 — Appeal From Adverse Determination.

62Q.731 APPEAL FROM ADVERSE DETERMINATION.
Subdivision 1.
Definitions.
(a) For purposes of this section, the terms defined in this subdivision have the meanings given.
(b) "Enrollee" means an eligible person as defined in section 62E.02, subdivision 13, and who meets the eligibility criteria established in section 62E.14.
(c) "Board" means the board of directors of the Comprehensive Health Association, as described in section 62E.10, subdivision 2.
Subd. 2.
Appeal to external review entity.
If an enrollee receives an adverse determination as a result of the Comprehensive Health Association's internal appeal process, by which an established enrollee appeal committee renders an adverse determination, the enrollee then has the option of:
(1) appealing the adverse determination to the external review entity under section 62Q.73, which shall constitute a final determination subject to the conditions specified in section 62Q.73; or
(2) appealing to the commissioner of commerce from an adverse determination as provided by the operating rules of the Comprehensive Health Association, in which case the commissioner has the option of making a determination regarding the appeal, or submitting the appeal to the external review entity retained under section 62Q.73.
History:
2002 c 330 s 29
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.733 — Definitions.

62Q.733 DEFINITIONS.
Subdivision 1.
Applicability.
For purposes of sections 62Q.732 to 62Q.739, the following definitions apply.
Subd. 2.
Contract.
"Contract" means a written agreement between a health care provider and a health plan company to provide health care services.
Subd. 3.
Health care provider or provider.
"Health care provider" or "provider" means a physician, advanced practice registered nurse, physician assistant, chiropractor, dentist, podiatrist, or other provider as defined under section 62J.03, other than hospitals, ambulatory surgical centers, or freestanding emergency rooms.
Subd. 4.
Health plan company.
(a) "Health plan company" means:
(1) a health maintenance organization operating under chapter 62D;
(2) a community integrated service network operating under chapter 62N;
(3) a preferred provider organization as defined in section 145.61, subdivision 4c; or
(4) an insurance company licensed under chapter 60A, nonprofit health service corporation operating under chapter 62C, fraternal benefit society operating under chapter 64B, or any other entity that establishes, operates, or maintains a health benefit plan or network of health care providers where the providers have entered into a contract with the entity to provide health care services.
(b) This subdivision does not apply to a health plan company with respect to coverage described in section 62A.011, subdivision 3, clauses (1) to (5) and (7) to (12).
Subd. 5.
Fee schedule.
"Fee schedule" means the total expected financial compensation paid to a health care provider for providing a health care service as determined by the contract between the health plan company and the provider, inclusive of withhold amounts and any amount for which the patient or other third party may be obligated to pay under the contract.
History:
2004 c 246 s 3; 2020 c 115 art 4 s 14; 2022 c 58 s 14
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.734 — Exemption.

62Q.734 EXEMPTION.
Sections 62Q.735 to 62Q.739 and 62Q.74 do not apply to health plan companies whose annual Minnesota health premium revenues are less than three percent of the total annual Minnesota health premium revenues, as measured by the assessment base of the Minnesota Comprehensive Health Association. For purposes of this percentage calculation, a health plan company's premiums include the Minnesota health premium revenues of its affiliates.
History:
2004 c 246 s 4
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.737 — Service Code Changes.

62Q.737 SERVICE CODE CHANGES.
(a) For purposes of this section, "service code" means current procedural terminology (CPT), current dental terminology (CDT), ICD-CM, diagnosis-related groups (DRGs), or other coding system.
(b) The health plan company shall determine the manner in which it adjudicates claims. The provider may request a description of the general coding guidelines applicable to the health care services the provider is reasonably expected to render pursuant to the contract. The health plan company or its designee shall provide the coding guidelines not later than 30 days after the date the health plan receives the request. The health plan company shall provide notice of material changes to the coding guidelines not later than 45 days prior to the date the changes take effect and shall not make retroactive revision to the coding guidelines, but may issue new guidelines. A provider who receives information under this section may use or disclose the information only for the purpose of practice management, billing activities, or other business operations and may not disclose the information to third parties without the consent of the health plan company.
(c) The health plan company may correct an error in a submitted claim that prevents the claim from being processed, provided that the health plan company:
(1) notifies the provider of the change and reason for the change according to federal Health Insurance Portability and Accountability Act (HIPAA) transaction standards; and
(2) offers the provider the opportunity to appeal any changes.
(d) Nothing in this section shall be interpreted to require a health plan company to violate copyright or other law by disclosing proprietary licensed software. In addition to the above, the health plan company shall, upon request of a contracted provider, disclose the name, edition, and model version of the software that the health plan company uses to determine bundling and unbundling of claims.
(e) This section does not apply to government programs, including state public programs, Medicare, and Medicare-related coverage.
History:
2004 c 246 s 7
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.739 — Unilateral Terms Prohibited.

62Q.739 UNILATERAL TERMS PROHIBITED.
(a) A contract between a health plan company and a health care provider shall not contain or require unilateral terms regarding indemnification or arbitration. Notwithstanding any prohibitions in this section, a contract between a health plan company and a health care provider may be unilaterally terminated by either party in accordance with the terms of the contract.
(b) A health plan company may not terminate or fail to renew a health care provider's contract without cause unless the company has given the provider a written notice of the termination or nonrenewal 120 days before the effective date.
History:
2004 c 246 s 8
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.746 — Access To Certain Information Regarding Providers.

62Q.746 ACCESS TO CERTAIN INFORMATION REGARDING PROVIDERS.
Upon request of the commissioner, a health plan company licensed under chapters 62C and 62D must provide the following information:
(1) a detailed description of the health plan company's methods and procedures, standards, qualifications, criteria, and credentialing requirements for designating the providers who are eligible to participate in the health plan company's provider network, including any limitations on the numbers of providers to be included in the network;
(2) the number of full-time equivalent physicians, by specialty, nonphysician providers, and allied health providers used to provide services; and
(3) summary data that is broken down by type of provider, reflecting actual utilization of network and non-network practitioners and allied professionals by enrollees of the health plan company.
History:
2001 c 170 s 7
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.751 — Collecting Deductibles And Coinsurance.

62Q.751 COLLECTING DEDUCTIBLES AND COINSURANCE.
A health plan company shall not prohibit providers from collecting deductibles and coinsurance from patients at or prior to the time of service. Providers may not withhold a service to a health plan company enrollee based on a patient's failure to pay a deductible or coinsurance at or prior to the time of service. Overpayments by patients to providers must be returned to the patient by the provider by check or electronic payment within 30 days of the date in which the claim adjudication is received by the provider.
History:
2010 c 331 s 6
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.76 — Definitions.

62Q.76 DEFINITIONS.
Subdivision 1.
Applicability.
For purposes of sections 62Q.76 to 62Q.79, the terms defined in this section have the meanings given them.
Subd. 2.
Dental care services.
"Dental care services" means services performed by a licensed dentist or any person working under the dentist's supervision as permitted under chapter 150A, which an enrollee might reasonably require to maintain good dental health, including preventive services, diagnostic services, emergency dental care, and restorative services.
Subd. 3.
Dental plan.
"Dental plan" means a policy, contract, or certificate offered by a dental organization for the coverage of dental care services. Dental plan means individual or group coverage.
Subd. 4.
Dentist.
"Dentist" means a person licensed to practice dentistry under chapter 150A.
Subd. 5.
Emergency dental care.
"Emergency dental care" means the provision of dental care services for a sudden, acute dental condition that would lead a prudent layperson to reasonably expect that the absence of immediate care would result in serious impairment to the dentition or would place the person's oral health in serious jeopardy.
Subd. 6.
Enrollee.
"Enrollee" means an individual covered by a dental organization and includes an insured, policyholder, subscriber, contract holder, member, covered person, or certificate holder.
Subd. 7.
Dental organization.
"Dental organization" means a health insurer licensed under chapter 60A; a health service plan corporation licensed under chapter 62C; a health maintenance organization licensed under chapter 62D; a community integrated service network licensed under chapter 62N; or a third-party administrator that:
(1) provides, either directly or through contracts with providers or other persons, dental care services;
(2) arranges for the provision of these services to enrollees on the basis of a fixed, prepaid sum without regard to the frequency or extent of services furnished to any particular enrollee; or
(3) administers dental plans.
Subd. 8.
Dental provider contract.
"Dental provider contract" means a written agreement between a dentist or dental clinic and dental organization to provide dental care services.
Subd. 9.
Third party.
"Third party" means a person or entity that enters into a contract with a dental organization or with another third party to gain access to the dental care services or contractual discounts under a dental provider contract. Third party does not include an enrollee of a dental organization or an employer or other group for whom the dental organization provides administrative services.
History:
2000 c 410 s 1; 2011 c 64 s 1; 2023 c 57 art 2 s 49
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62Q — Health Plan Companies › Section 62Q.77 — Terms Of Coverage Disclosure.

62Q.77 TERMS OF COVERAGE DISCLOSURE.
A dental organization shall make available to an enrollee, upon request, a clear and concise description of the following terms of coverage:
(1) the dental care services and other benefits to which the enrollee is entitled under the dental plan;
(2) any exclusions or limitation on the services, kind of services, benefits, or kind of benefits to be provided, including any deductible or co-payment features and any requirements for referrals to specialists;
(3) a description as to how services, including emergency dental care and out-of-area service, may be obtained;
(4) a general description of payment and co-payment amounts, if any, for dental care services, which the enrollee is obligated to pay; and
(5) a telephone number by which the enrollee may obtain additional information regarding coverage.
History:
2000 c 410 s 2