reglab/statecodes huggingface dataset:
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.73 — Prohibition On Exclusive Arrangements.

62J.73 PROHIBITION ON EXCLUSIVE ARRANGEMENTS.
Subdivision 1.
Prohibition on exclusive relationships.
No provider, group of providers, or health plan company shall restrict a person's right to provide health services or procedures to another provider, group of providers, or health plan company, unless the person is an employee.
Subd. 2.
Prohibition on restrictive contract terms.
No provider, group of providers, or person providing goods or health services to a provider shall enter into a contract or subcontract with a health plan company or group of providers on terms that require the provider, group of providers, or person not to contract with another health plan company, unless the provider or person is an employee.
Subd. 3.
Prohibition regarding essential facilities and services.
(a) No health plan company, provider, or group of providers may withhold from its competitors health care services, which are essential for competition between health care providers within the meaning of the essential facilities doctrine as interpreted by the federal courts.
(b) This subdivision should be construed as an instruction to state court in interpreting federal law.
Subd. 4.
Violations.
Any provider or other individual who believes provisions of this section may have been violated may file a complaint with the attorney general's office regarding a possible violation of this section.
History:
1997 c 237 s 5
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.74 — Enforcement.

62J.74 ENFORCEMENT.
Subdivision 1.
Authority.
The commissioners of health and commerce shall each periodically review contracts and arrangements among health care providing entities and health plan companies they regulate to determine compliance with sections 62J.70 to 62J.73. Any person may submit a contract or arrangement to the relevant commissioner for review if the person believes sections 62J.70 to 62J.73 have been violated. Any provision of a contract or arrangement found by the relevant commissioner to violate this section is null and void, and the relevant commissioner may assess civil penalties against the health plan company in an amount not to exceed $2,500 for each day the contract or arrangement is in effect, and may use the enforcement procedures otherwise available to the commissioner. All due process rights afforded under chapter 14 apply to this section.
Subd. 2.
Assistance to licensing boards.
A health-related licensing board as defined under section 214.01, subdivision 2, shall submit a contract or arrangement to the relevant commissioner for review if the board believes sections 62J.70 to 62J.73 have been violated. If the commissioner determines that any provision of a contract or arrangement violates those sections, the board may take disciplinary action against any person who is licensed or regulated by the board who entered into the contract arrangement.
History:
1997 c 237 s 6
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.76 — Nonpreemption.

62J.76 NONPREEMPTION.
Nothing in the Patient Protection Act preempts or replaces requirements related to patient protections that are more protective of patient rights than the requirements established by the Patient Protection Act.
History:
1997 c 237 s 8
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.80 — Retaliation.

62J.80 RETALIATION.
A health plan company or health care provider shall not retaliate or take adverse action against an enrollee or patient who, in good faith, makes a complaint against a health plan company or health care provider. If retaliation is suspected, the executive director may report it to the appropriate regulatory authority.
History:
1998 c 407 art 2 s 18
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.811 — Provider Balance Billing Requirements.

62J.811 PROVIDER BALANCE BILLING REQUIREMENTS.
Subdivision 1.
Billing requirements.
(a) Each health care provider and health facility shall comply with the federal Consolidated Appropriations Act, 2021, Division BB also known as the "No Surprises Act," including any federal regulations adopted under that act.
(b) For the purposes of this section, "provider" or "facility" means any health care provider or facility pursuant to section 62A.63, subdivision 2, or 62J.03, subdivision 8, that is subject to relevant provisions of the No Surprises Act.
Subd. 2.
Investigations and compliance.
(a) The commissioner shall, to the extent practicable, seek the cooperation of health care providers and facilities, and may provide any support and assistance as available, in obtaining compliance with this section.
(b) The commissioner shall determine the manner and processes for fulfilling any responsibilities and taking any of the actions in paragraphs (c) to (f).
(c) A person who believes a health care provider or facility has not complied with the requirements of the No Surprises Act or this section may file a complaint with the commissioner in the manner determined by the commissioner.
(d) The commissioner shall conduct compliance reviews and investigate complaints filed under this section in the manner determined by the commissioner to ascertain whether health care providers and facilities are complying with this section.
(e) The commissioner may report violations under this section to other relevant federal and state departments and jurisdictions as appropriate, including the attorney general and relevant licensing boards, and may also coordinate on investigations and enforcement of this section with other relevant federal and state departments and jurisdictions as appropriate, including the attorney general and relevant licensing boards.
(f) A health care provider or facility may contest whether the finding of facts constitute a violation of this section according to the contested case proceeding in sections 14.57 to 14.62, subject to appeal according to sections 14.63 to 14.68.
(g) Any data collected by the commissioner as part of an active investigation or active compliance review under this section are classified (1) if the data is not on individuals, it is classified as protected nonpublic data pursuant to section 13.02 subdivision 13; or (2) if the data is on individuals, it is classified as confidential pursuant to section 13.02, subdivision 3. Data describing the final disposition of an investigative or compliance review are classified as public.
Subd. 3.
Civil penalty.
(a) The commissioner, in monitoring and enforcing this section, may levy a civil monetary penalty against each health care provider or facility found to be in violation of up to $100 for each violation, but may not exceed $25,000 for identical violations during a calendar year.
(b) No civil monetary penalty shall be imposed under this section for violations that occur prior to January 1, 2024.
History:
2023 c 70 art 2 s 5
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.812 — Primary Care Price Transparency.

62J.812 PRIMARY CARE PRICE TRANSPARENCY.
(a) Each provider shall maintain a list of the services over $25 that correspond with the provider's 25 most frequently billed current procedural terminology (CPT) codes, including the provider's ten most commonly billed evaluation and management codes, and of the ten most frequently billed CPT codes for preventive services. If the provider is associated with a health care system, the health care system may develop the list of services required under this paragraph for the providers within the health care system.
(b) For each service listed in paragraph (a), the provider shall disclose the provider's charge, the average reimbursement rate received for the service from the provider's health plan payers in the commercial insurance market, and, if applicable, the Medicare allowable payment rate and the medical assistance fee-for-service payment rate. For purposes of this paragraph, "provider's charge" means the dollar amount the provider charges to a patient who has received the service and who is not covered by private or public health care coverage.
(c) The list described in this subdivision must be updated annually and must be posted in the provider's reception area of the clinic or office and made available on the provider's website, if the provider maintains a website.
(d) For purposes of this section, "provider" means a primary care provider or clinic that specializes in family medicine, general internal medicine, gynecology, or general pediatrics.
(e) No contract between a health plan company and a provider shall prohibit a provider from disclosing the pricing information required under this section.
History:
2018 c 168 s 2; 2020 c 83 art 1 s 10
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.82 — Hospital Information Reporting Disclosure.

62J.82 HOSPITAL INFORMATION REPORTING DISCLOSURE.
Subdivision 1.
Required information.
The Minnesota Hospital Association shall develop a web-based system, available to the public free of charge, for reporting the following, for Minnesota residents:
(1) hospital-specific performance on the measures of care developed under section 256B.072 for acute myocardial infarction, heart failure, and pneumonia;
(2) by January 1, 2009, hospital-specific performance on the public reporting measures for hospital-acquired infections as published by the National Quality Forum and collected by the Minnesota Hospital Association and Stratis Health in collaboration with infection control practitioners; and
(3) charge information, including, but not limited to, number of discharges, average length of stay, average charge, average charge per day, and median charge, for each of the 50 most common inpatient diagnosis-related groups and the 25 most common outpatient surgical procedures as specified by the Minnesota Hospital Association.
Subd. 2.
Website.
The website must provide information that compares hospital-specific data to hospital statewide data. The website must be updated annually. The commissioner shall provide a link to this reporting information on the department's website.
Subd. 3.
Enforcement.
The commissioner shall provide a link to this information on the department's website. If a hospital does not provide this information to the Minnesota Hospital Association, the commissioner of health may require the hospital to do so in accordance with section 144.55, subdivision 6.
History:
1Sp2005 c 4 art 8 s 2; 2007 c 147 art 14 s 1
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.823 — Hospital Pricing Transparency.

62J.823 HOSPITAL PRICING TRANSPARENCY.
Subdivision 1.
Short title.
This section may be cited as the "Hospital Pricing Transparency Act."
Subd. 2.
Definition.
For the purposes of this section, "estimate" means the actual price expected to be billed to the individual or to the individual's health plan company based on the specific diagnostic-related group code or specific procedure code or codes, reflecting any known discounts the individual would receive.
Subd. 3.
Applicability and scope.
Any hospital, as defined in section 144.696, subdivision 3, and outpatient surgical center, as defined in section 144.696, subdivision 4, shall provide a written estimate of the cost of a specific service or stay upon the request of a patient, a doctor, an advanced practice registered nurse, a physician assistant, or the patient's representative. The request must include:
(1) the health coverage status of the patient, including the specific health plan or other health coverage under which the patient is enrolled, if any; and
(2) at least one of the following:
(i) the specific diagnostic-related group code;
(ii) the name of the procedure or procedures to be performed;
(iii) the type of treatment to be received; or
(iv) any other information that will allow the hospital or outpatient surgical center to determine the specific diagnostic-related group or procedure code or codes.
Subd. 4.
Estimate.
(a) An estimate provided by the hospital or outpatient surgical center must contain:
(1) the method used to calculate the estimate;
(2) the specific diagnostic-related group or procedure code or codes used to calculate the estimate, and a description of the diagnostic-related group or procedure code or codes that is reasonably understandable to a patient; and
(3) a statement indicating that the estimate, while accurate, may not reflect the actual billed charges and that the final bill may be higher or lower depending on the patient's specific circumstances.
(b) The estimate may be provided in any method that meets the needs of the patient and the hospital or outpatient surgical center, including electronically; however, a paper copy must be provided if specifically requested.
History:
2006 c 255 s 25; 2020 c 115 art 4 s 7; 2022 c 58 s 10
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.824 — Facility Fee Disclosure.

62J.824 FACILITY FEE DISCLOSURE.
(a) Prior to the delivery of nonemergency services, a provider-based clinic that charges a facility fee shall provide notice to any patient, including patients served by telehealth as defined in section 62A.673, subdivision 2, paragraph (h), stating that the clinic is part of a hospital and the patient may receive a separate charge or billing for the facility component, which may result in a higher out-of-pocket expense.
(b) Each health care facility must post prominently in locations easily accessible to and visible by patients, including on its website, a statement that the provider-based clinic is part of a hospital and the patient may receive a separate charge or billing for the facility, which may result in a higher out-of-pocket expense.
(c) This section does not apply to laboratory services, imaging services, or other ancillary health services that are provided by staff who are not employed by the health care facility or clinic.
(d) For purposes of this section:
(1) "facility fee" means any separate charge or billing by a provider-based clinic in addition to a professional fee for physicians' services that is intended to cover building, electronic medical records systems, billing, and other administrative and operational expenses; and
(2) "provider-based clinic" means the site of an off-campus clinic or provider office, located at least 250 yards from the main hospital buildings or as determined by the Centers for Medicare and Medicaid Services, that is owned by a hospital licensed under chapter 144 or a health system that operates one or more hospitals licensed under chapter 144, and is primarily engaged in providing diagnostic and therapeutic care, including medical history, physical examinations, assessment of health status, and treatment monitoring. This definition does not include clinics that are exclusively providing laboratory, x-ray, testing, therapy, pharmacy, or educational services and does not include facilities designated as rural health clinics.
History:
2019 c 7 s 1; 2023 c 70 art 2 s 6
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.83 — Reduced Payment Amounts Permitted.

62J.83 REDUCED PAYMENT AMOUNTS PERMITTED.
(a) Notwithstanding any provision of chapter 148 or any other provision of law to the contrary, a health care provider may provide care to a patient at a discounted payment amount, including care provided for free.
(b) This section does not apply in a situation in which the discounted payment amount is not permitted under federal law.
History:
2006 c 255 s 26; 2008 c 344 s 56; 2009 c 86 art 1 s 88
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.841 — Definitions.

62J.841 DEFINITIONS.
Subdivision 1.
Scope.
For purposes of sections 62J.841 to 62J.845, the following definitions apply.
Subd. 2.
Consumer Price Index.
"Consumer Price Index" means the Consumer Price Index, Annual Average, for All Urban Consumers, CPI-U: U.S. City Average, All Items, reported by the United States Department of Labor, Bureau of Labor Statistics, or its successor or, if the index is discontinued, an equivalent index reported by a federal authority or, if no such index is reported, "Consumer Price Index" means a comparable index chosen by the Bureau of Labor Statistics.
Subd. 3.
Generic or off-patent drug.
"Generic or off-patent drug" means any prescription drug for which any exclusive marketing rights granted under the Federal Food, Drug, and Cosmetic Act, section 351 of the federal Public Health Service Act, and federal patent law have expired, including any drug-device combination product for the delivery of a generic drug.
Subd. 4.
Manufacturer.
"Manufacturer" has the meaning given in section 151.01, subdivision 14a, but does not include an entity that must be licensed solely because the entity repackages or relabels drugs.
Subd. 5.
Prescription drug.
"Prescription drug" means a drug for human use subject to United States Code, title 21, section 353(b)(1).
Subd. 6.
Wholesale acquisition cost.
"Wholesale acquisition cost" has the meaning provided in United States Code, title 42, section 1395w-3a.
Subd. 7.
Wholesale distributor.
"Wholesale distributor" has the meaning provided in section 151.441, subdivision 14.
History:
2023 c 57 art 2 s 22
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.842 — Excessive Price Increases Prohibited.

62J.842 EXCESSIVE PRICE INCREASES PROHIBITED.
Subdivision 1.
Prohibition.
No manufacturer shall impose, or cause to be imposed, an excessive price increase, whether directly or through a wholesale distributor, pharmacy, or similar intermediary, on the sale of any generic or off-patent drug sold, dispensed, or delivered to any consumer in the state.
Subd. 2.
Excessive price increase.
A price increase is excessive for purposes of this section when:
(1) the price increase, adjusted for inflation utilizing the Consumer Price Index, exceeds:
(i) 15 percent of the wholesale acquisition cost over the immediately preceding calendar year; or
(ii) 40 percent of the wholesale acquisition cost over the immediately preceding three calendar years; and
(2) the price increase, adjusted for inflation utilizing the Consumer Price Index, exceeds $30 for:
(i) a 30-day supply of the drug; or
(ii) a course of treatment lasting less than 30 days.
Subd. 3.
Exemption.
It is not a violation of this section for a wholesale distributor or pharmacy to increase the price of a generic or off-patent drug if the price increase is directly attributable to additional costs for the drug imposed on the wholesale distributor or pharmacy by the manufacturer of the drug.
History:
2023 c 57 art 2 s 23
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.843 — Registered Agent And Office Within The State.

62J.843 REGISTERED AGENT AND OFFICE WITHIN THE STATE.
Any manufacturer that sells, distributes, delivers, or offers for sale any generic or off-patent drug in the state must maintain a registered agent and office within the state.
History:
2023 c 57 art 2 s 24
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.845 — Prohibition On Withdrawal Of Generic Or Off-patent Drugs For Sale.

62J.845 PROHIBITION ON WITHDRAWAL OF GENERIC OR OFF-PATENT DRUGS FOR SALE.
Subdivision 1.
Prohibition.
A manufacturer of a generic or off-patent drug is prohibited from withdrawing that drug from sale or distribution within this state for the purpose of avoiding the prohibition on excessive price increases under section 62J.842.
Subd. 2.
Notice to board and attorney general.
Any manufacturer that intends to withdraw a generic or off-patent drug from sale or distribution within the state shall provide a written notice of withdrawal to the attorney general at least 90 days prior to the withdrawal.
Subd. 3.
Financial penalty.
The attorney general shall assess a penalty of $500,000 on any manufacturer of a generic or off-patent drug that the attorney general determines has failed to comply with the requirements of this section.
History:
2023 c 57 art 2 s 26
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.846 — Severability.

62J.846 SEVERABILITY.
If any provision of sections 62J.841 to 62J.845 or the application thereof to any person or circumstance is held invalid for any reason in a court of competent jurisdiction, the invalidity does not affect other provisions or any other application of sections 62J.841 to 62J.845 that can be given effect without the invalid provision or application.
History:
2023 c 57 art 2 s 27
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.86 — Definitions.

62J.86 DEFINITIONS.
Subdivision 1.
Definitions.
For the purposes of sections 62J.85 to 62J.95, the following terms have the meanings given.
Subd. 2.
Advisory council.
"Advisory council" means the Prescription Drug Affordability Advisory Council established under section 62J.88.
Subd. 3.
Biologic.
"Biologic" means a drug that is produced or distributed in accordance with a biologics license application approved under Code of Federal Regulations, title 42, section 447.502.
Subd. 4.
Biosimilar.
"Biosimilar" has the meaning provided in section 62J.84, subdivision 2, paragraph (b).
Subd. 5.
Board.
"Board" means the Prescription Drug Affordability Board established under section 62J.87.
Subd. 6.
Brand name drug.
"Brand name drug" means a drug that is produced or distributed pursuant to:
(1) a new drug application approved under United States Code, title 21, section 355(c), except for a generic drug as defined under Code of Federal Regulations, title 42, section 447.502; or
(2) a biologics license application approved under United States Code, title 45, section 262(a)(c).
Subd. 7.
Generic drug.
"Generic drug" has the meaning provided in section 62J.84, subdivision 2, paragraph (e).
Subd. 8.
Group purchaser.
"Group purchaser" has the meaning given in section 62J.03, subdivision 6, and includes pharmacy benefit managers, as defined in section 62W.02, subdivision 15.
Subd. 9.
Manufacturer.
"Manufacturer" means an entity that:
(1) engages in the manufacture of a prescription drug product or enters into a lease with another manufacturer to market and distribute a prescription drug product under the entity's own name; and
(2) sets or changes the wholesale acquisition cost of the prescription drug product it manufacturers or markets.
Subd. 10.
Prescription drug product.
"Prescription drug product" means a brand name drug, a generic drug, a biologic, or a biosimilar.
Subd. 11.
Wholesale acquisition cost or WAC.
"Wholesale acquisition cost" or "WAC" has the meaning given in United States Code, title 42, section 1395W-3a(c)(6)(B).
History:
2023 c 57 art 2 s 29
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.88 — Prescription Drug Affordability Advisory Council.

62J.88 PRESCRIPTION DRUG AFFORDABILITY ADVISORY COUNCIL.
Subdivision 1.
Establishment.
The governor shall appoint a 18-member stakeholder advisory council to provide advice to the board on drug cost issues and to represent stakeholders' views. The governor shall appoint the members of the advisory council based on the members' knowledge and demonstrated expertise in one or more of the following areas: the pharmaceutical business; practice of medicine; patient perspectives; health care cost trends and drivers; clinical and health services research; and the health care marketplace.
Subd. 2.
Membership.
The council's membership shall consist of the following:
(1) two members representing patients and health care consumers;
(2) two members representing health care providers;
(3) one member representing health plan companies;
(4) two members representing employers, with one member representing large employers and one member representing small employers;
(5) one member representing government employee benefit plans;
(6) one member representing pharmaceutical manufacturers;
(7) one member who is a health services clinical researcher;
(8) one member who is a pharmacologist;
(9) one member representing the commissioner of health with expertise in health economics;
(10) one member representing pharmaceutical wholesalers;
(11) one member representing pharmacy benefit managers;
(12) one member from the Rare Disease Advisory Council;
(13) one member representing generic drug manufacturers;
(14) one member representing pharmaceutical distributors; and
(15) one member who is an oncologist who is not employed by, under contract with, or otherwise affiliated with a hospital.
Subd. 3.
Terms.
(a) The initial appointments to the advisory council must be made by January 1, 2024. The initial appointed advisory council members shall serve staggered terms of two, three, or four years, determined by lot by the secretary of state. Following the initial appointments, the advisory council members shall serve four-year terms.
(b) Removal and vacancies of advisory council members shall be governed by section 15.059.
Subd. 4.
Compensation.
Advisory council members may be compensated according to section 15.059, except that those advisory council members designated in subdivision 2, clauses (10) to (15), must not be compensated.
Subd. 5.
Meetings.
Meetings of the advisory council are subject to chapter 13D. The advisory council shall meet publicly at least every three months to advise the board on drug cost issues related to the prescription drug product information submitted to the board under section 62J.90.
Subd. 6.
Exemption.
Notwithstanding section 15.059, the advisory council shall not expire.
History:
2023 c 57 art 2 s 31
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.89 — Conflicts Of Interest.

62J.89 CONFLICTS OF INTEREST.
Subdivision 1.
Definition.
For purposes of this section, "conflict of interest" means a financial or personal association that has the potential to bias or have the appearance of biasing a person's decisions in matters related to the board, the advisory council, or in the conduct of the board's or council's activities. A conflict of interest includes any instance in which a person, a person's immediate family member, including a spouse, parent, child, or other legal dependent, or an in-law of any of the preceding individuals, has received or could receive a direct or indirect financial benefit of any amount deriving from the result or findings of a decision or determination of the board. For purposes of this section, a financial benefit includes honoraria, fees, stock, the value of the member's, immediate family member's, or in-law's stock holdings, and any direct financial benefit deriving from the finding of a review conducted under sections 62J.85 to 62J.95. Ownership of securities is not a conflict of interest if the securities are: (1) part of a diversified mutual or exchange traded fund; or (2) in a tax-deferred or tax-exempt retirement account that is administered by an independent trustee.
Subd. 2.
General.
(a) Prior to the acceptance of an appointment or employment, or prior to entering into a contractual agreement, a board or advisory council member, board staff member, or third-party contractor must disclose to the appointing authority or the board any conflicts of interest. The information disclosed must include the type, nature, and magnitude of the interests involved.
(b) A board member, board staff member, or third-party contractor with a conflict of interest with regard to any prescription drug product under review must recuse themselves from any discussion, review, decision, or determination made by the board relating to the prescription drug product.
(c) Any conflict of interest must be disclosed in advance of the first meeting after the conflict is identified or within five days after the conflict is identified, whichever is earlier.
Subd. 3.
Prohibitions.
Board members, board staff, or third-party contractors are prohibited from accepting gifts, bequeaths, or donations of services or property that raise the specter of a conflict of interest or have the appearance of injecting bias into the activities of the board.
History:
2023 c 57 art 2 s 32
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.91 — Prescription Drug Product Reviews.

62J.91 PRESCRIPTION DRUG PRODUCT REVIEWS.
Subdivision 1.
General.
Once a decision by the board has been made to proceed with a cost review of a prescription drug product, the board shall conduct the review and make a determination as to whether appropriate utilization of the prescription drug under review, based on utilization that is consistent with the United States Food and Drug Administration (FDA) label or standard medical practice, has led or will lead to affordability challenges for the state health care system or for patients.
Subd. 2.
Review considerations.
In reviewing the cost of a prescription drug product, the board may consider the following factors:
(1) the price at which the prescription drug product has been and will be sold in the state;
(2) manufacturer monetary price concessions, discounts, or rebates, and drug-specific patient assistance;
(3) the price of therapeutic alternatives;
(4) the cost to group purchasers based on patient access consistent with the FDA-labeled indications and standard medical practice;
(5) measures of patient access, including cost-sharing and other metrics;
(6) the extent to which the attorney general or a court has determined that a price increase for a generic or off-patent prescription drug product was excessive under sections 62J.842 and 62J.844;
(7) any information a manufacturer chooses to provide; and
(8) any other factors as determined by the board.
Subd. 3.
Public data; proprietary information.
(a) Any submission made to the board related to a drug cost review must be made available to the public with the exception of information determined by the board to be proprietary and information provided by the commissioner of health classified as not public data under section 13.02, subdivision 8a, or as trade secret information under section 13.37, subdivision 1, paragraph (b), or as trade secret information under the Defend Trade Secrets Act of 2016, United States Code, title 18, section 1836, as amended.
(b) The board shall establish the standards for the information to be considered proprietary under paragraph (a) and section 62J.90, subdivision 2, including standards for heightened consideration of proprietary information for submissions for a cost review of a drug that is not yet approved by the FDA.
(c) Prior to the board establishing the standards under paragraph (b), the public shall be provided notice and the opportunity to submit comments.
(d) The establishment of standards under this subdivision is exempt from the rulemaking requirements under chapter 14, and section 14.386 does not apply.
History:
2023 c 57 art 2 s 34
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.93 — Reports.

62J.93 REPORTS.
Beginning March 1, 2024, and each March 1 thereafter, the board shall submit a report to the governor and legislature on general price trends for prescription drug products and the number of prescription drug products that were subject to the board's cost review and analysis, including the result of any analysis as well as the number and disposition of appeals and judicial reviews.
History:
2023 c 57 art 2 s 36
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.94 — Erisa Plans And Medicare Drug Plans.

62J.94 ERISA PLANS AND MEDICARE DRUG PLANS.
(a) Nothing in sections 62J.85 to 62J.95 shall be construed to require ERISA plans or Medicare Part D plans to comply with decisions of the board. ERISA plans or Medicare Part D plans are free to choose to exceed the upper payment limit established by the board under section 62J.92.
(b) Providers who dispense and administer drugs in the state must bill all payers no more than the upper payment limit without regard to whether an ERISA plan or Medicare Part D plan chooses to reimburse the provider in an amount greater than the upper payment limit established by the board.
(c) For purposes of this section, an ERISA plan or group health plan is an employee welfare benefit plan established by or maintained by an employer or an employee organization, or both, that provides employer sponsored health coverage to employees and the employee's dependents and is subject to the Employee Retirement Income Security Act of 1974 (ERISA).
History:
2023 c 57 art 2 s 37
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62J — Health Care Cost Containment › Section 62J.95 — Severability.

62J.95 SEVERABILITY.
If any provision of sections 62J.85 to 62J.94 or the application thereof to any person or circumstance is held invalid for any reason in a court of competent jurisdiction, the invalidity does not affect other provisions or any other application of sections 62J.85 to 62J.94 that can be given effect without the invalid provision or application.
History:
2023 c 57 art 2 s 38
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.02 — Purpose And Scope.

62K.02 PURPOSE AND SCOPE.
Subdivision 1.
Purpose.
The market rules set forth in this chapter serve to clarify and provide guidance on the application of state law and certain requirements of the Affordable Care Act on all health carriers offering health plans in Minnesota, whether or not through MNsure, to ensure fair competition for all health carriers in Minnesota, to minimize adverse selection, and to ensure that health plans are offered in a manner that protects consumers and promotes the provision of high-quality affordable health care, and improved health outcomes. This chapter contains the regulatory requirements as specified in section 62V.05, subdivision 5, paragraph (b), and shall fully satisfy the requirements of section 62V.05, subdivision 5, paragraph (b).
Subd. 2.
Scope.
(a) This chapter applies only to health plans offered in the individual market or the small group market.
(b) This chapter applies to health carriers with respect to individual health plans and small group health plans, unless otherwise specified.
(c) If a health carrier issues or renews individual or small group health plans in other states, this chapter applies only to health plans issued or renewed in this state to a Minnesota resident, or to cover a resident of the state, or issued or renewed to a small employer that is actively engaged in business in this state, unless otherwise specified.
(d) This chapter does not apply to short-term coverage as defined in section 62A.65, subdivision 7, or grandfathered plan coverage as defined in section 62A.011, subdivision 1b.
History:
2013 c 84 art 2 s 3; 2013 c 108 art 1 s 67
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.03 — Definitions.

62K.03 DEFINITIONS.
Subdivision 1.
Applicability.
For purposes of this chapter, the terms defined in this section have the meanings given.
Subd. 2.
Affordable Care Act.
"Affordable Care Act" means the federal Patient Protection and Affordable Care Act, Public Law 111-148, as amended, including the federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and any amendments, and any federal guidance or regulations issued under these acts.
Subd. 3.
Dental plan.
"Dental plan" means a dental plan as defined in section 62Q.76, subdivision 3.
Subd. 4.
Enrollee.
"Enrollee" means a natural person covered by a health plan and includes an insured policyholder, subscriber, contract holder, member, covered person, or certificate holder.
Subd. 5.
Health carrier.
"Health carrier" means a health carrier as defined in section 62A.011, subdivision 2.
Subd. 6.
Health plan.
"Health plan" means a health plan as defined in section 62A.011, subdivision 3.
Subd. 7.
Individual health plan.
"Individual health plan" means an individual health plan as defined in section 62A.011, subdivision 4.
Subd. 8.
Limited-scope pediatric dental plan.
"Limited-scope pediatric dental plan" means a dental plan meeting the requirements of section 9832(c)(2)(A) of the Internal Revenue Code of 1986, as amended, that provides only pediatric dental benefits meeting the requirements of the Affordable Care Act and is offered by a health carrier. A limited-scope pediatric dental plan includes a dental plan that is offered separately or in conjunction with an individual or small group health plan to individuals who have not attained the age of 19 years as of the beginning of the policy year or to a family.
Subd. 9.
MNsure.
"MNsure" means MNsure as defined in section 62V.02.
Subd. 10.
Preferred provider organization.
"Preferred provider organization" means a health plan that provides discounts to enrollees or subscribers for services they receive from certain health care providers.
Subd. 11.
Qualified health plan.
"Qualified health plan" means a health plan that meets the definition in the Affordable Care Act and has been certified by the board of MNsure in accordance with chapter 62V to be offered through MNsure.
Subd. 12.
Small group health plan.
"Small group health plan" means a health plan issued by a health carrier to a small employer as defined in section 62L.02, subdivision 26.
History:
2013 c 84 art 2 s 4; 2013 c 108 art 1 s 67
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.04 — Market Rules; Violation.

62K.04 MARKET RULES; VIOLATION.
Subdivision 1.
Compliance.
(a) A health carrier issuing an individual health plan to a Minnesota resident or a small group health plan to provide coverage to a small employer that is actively engaged in business in Minnesota shall meet all of the requirements set forth in this chapter. The failure to meet any of the requirements under this chapter constitutes a violation of section 72A.20.
(b) The requirements of this chapter do not apply to short-term coverage as defined in section 62A.65, subdivision 7, or grandfathered plan coverage as defined in section 62A.011, subdivision 1c.
Subd. 2.
Penalties.
In addition to any other penalties provided by the laws of this state or by federal law, a health carrier or any other person found to have violated any requirement of this chapter may be subject to the administrative procedures, enforcement actions, and penalties provided under section 45.027 and chapters 62D and 72A.
History:
2013 c 84 art 2 s 5
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.05 — Federal Act; Compliance Required.

62K.05 FEDERAL ACT; COMPLIANCE REQUIRED.
A health carrier shall comply with all provisions of the Affordable Care Act to the extent that it imposes a requirement that applies in this state. Compliance with any provision of the Affordable Care Act is required as of the effective date established for that provision in the federal act, except as otherwise specifically stated earlier in state law.
History:
2013 c 84 art 2 s 6
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.06 — Metal Level Mandatory Offerings.

62K.06 METAL LEVEL MANDATORY OFFERINGS.
Subdivision 1.
Identification.
A health carrier that offers individual or small group health plans in Minnesota must provide documentation to the commissioner of commerce to justify actuarial value levels as specified in section 1302(d) of the Affordable Care Act for all individual and small group health plans offered inside and outside of MNsure.
Subd. 2.
Minimum levels.
(a) A health carrier that offers a catastrophic plan or a bronze level health plan within a service area in either the individual or small group market must also offer a silver level and a gold level health plan in that market and within that service area.
(b) A health carrier with less than five percent market share in the respective individual or small group market in Minnesota is exempt from paragraph (a), until January 1, 2017, unless the health carrier offers a qualified health plan through MNsure. If the health carrier offers a qualified health plan through MNsure, the health carrier must comply with paragraph (a).
Subd. 3.
MNsure restriction.
MNsure may not, by contract or otherwise, mandate the types of health plans to be offered by a health carrier to individuals or small employers purchasing health plans outside of MNsure. Solely for purposes of this subdivision, "health plan" includes coverage that is excluded under section 62A.011, subdivision 3, clause (6).
Subd. 4.
Metal level defined.
For purposes of this section, the metal levels and catastrophic plans are defined in section 1302(d) and (e) of the Affordable Care Act.
Subd. 5.
Enforcement.
The commissioner of commerce shall enforce this section.
History:
2013 c 84 art 2 s 7,17; 2013 c 108 art 1 s 67
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.075 — Provider Network Notifications.

62K.075 PROVIDER NETWORK NOTIFICATIONS.
(a) A health carrier must provide on the carrier's website the provider network for each product offered by the carrier, and must update the carrier's website at least once a month with any changes to the carrier's provider network, including provider changes from in-network status to out-of-network status. A health carrier must also provide on the carrier's website, for each product offered by the carrier, a list of the current waivers of the requirements in section 62K.10, subdivision 2 or 3, in a format that is easily accessed and searchable by enrollees and prospective enrollees.
(b) Upon notification from an enrollee, a health carrier must reprocess any claim for services provided by a provider whose status has changed from in-network to out-of-network as an in-network claim if the service was provided after the network change went into effect but before the change was posted as required under paragraph (a) unless the health carrier notified the enrollee of the network change prior to the service being provided. This paragraph does not apply if the health carrier is able to verify that the health carrier's website displayed the correct provider network status on the health carrier's website at the time the service was provided.
(c) The limitations of section 62Q.56, subdivision 2a, shall apply to payments required by paragraph (b).
History:
2016 c 179 s 1; 1Sp2019 c 9 art 8 s 9
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.08 — Marketing Standards.

62K.08 MARKETING STANDARDS.
Subdivision 1.
Marketing.
(a) A health carrier offering individual or small group health plans must comply with all applicable provisions of the Affordable Care Act, including, but not limited to, the following:
(1) compliance with all state laws pertaining to the marketing of individual or small group health plans; and
(2) establishing marketing practices and benefit designs that will not have the effect of discouraging the enrollment of individuals with significant health needs in the health plan.
(b) No marketing materials may lead consumers to believe that all health care needs will be covered.
Subd. 2.
Enforcement.
The commissioner of commerce shall enforce this section.
History:
2013 c 84 art 2 s 9
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.09 — Accreditation Standards.

62K.09 ACCREDITATION STANDARDS.
Subdivision 1.
Accreditation; general.
(a) A health carrier that offers any individual or small group health plans in Minnesota outside of MNsure must be accredited in accordance with this subdivision. A health carrier must obtain accreditation through URAC, the National Committee for Quality Assurance (NCQA), or any entity recognized by the United States Department of Health and Human Services for accreditation of health insurance issuers or health plans by January 1, 2018. Proof of accreditation must be submitted to the commissioner of health in a form prescribed by the commissioner of health.
(b) A health carrier that rents a provider network is exempt from this subdivision, unless it is part of a holding company as defined in section 60D.15 that in aggregate exceeds ten percent market share in either the individual or small group market in Minnesota.
Subd. 2.
Accreditation; MNsure.
(a) MNsure shall require all health carriers offering a qualified health plan through MNsure to obtain the appropriate level of accreditation no later than the third year after the first year the health carrier offers a qualified health plan through MNsure. A health carrier must take the first step of the accreditation process during the first year in which it offers a qualified health plan. A health carrier that offers a qualified health plan on January 1, 2014, must obtain accreditation by the end of the 2016 plan year.
(b) To the extent a health carrier cannot obtain accreditation due to low volume of enrollees, an exception to this accreditation criterion may be granted by MNsure until such time as the health carrier has a sufficient volume of enrollees.
Subd. 3.
Oversight.
A health carrier shall comply with a request from the commissioner of health to confirm accreditation or progress toward accreditation.
Subd. 4.
Enforcement.
The commissioner of health shall enforce this section.
History:
2013 c 84 art 2 s 10,17; 2013 c 108 art 1 s 67
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.105 — Network Adequacy Complaints.

62K.105 NETWORK ADEQUACY COMPLAINTS.
The commissioner of health shall establish a clear, easily accessible process for accepting complaints from enrollees regarding health carrier compliance with section 62K.10, subdivision 2, 3, or 4. Using this process, an enrollee may file a complaint with the commissioner that a health carrier is not in compliance with the requirements of section 62K.10, subdivision 2, 3, or 4. The commissioner of health shall investigate all complaints received under this section.
History:
1Sp2019 c 9 art 8 s 11
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.11 — Balance Billing Prohibited.

62K.11 BALANCE BILLING PROHIBITED.
(a) A network provider is prohibited from billing an enrollee for any amount in excess of the allowable amount the health carrier has contracted for with the provider as total payment for the health care service. A network provider is permitted to bill an enrollee the approved co-payment, deductible, or coinsurance.
(b) A network provider is permitted to bill an enrollee for services not covered by the enrollee's health plan as long as the enrollee agrees in writing in advance before the service is performed to pay for the noncovered service.
History:
2013 c 84 art 2 s 12