reglab/statecodes huggingface dataset:
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.12 — Quality Assurance And Improvement.

62K.12 QUALITY ASSURANCE AND IMPROVEMENT.
Subdivision 1.
General.
(a) All health carriers offering an individual health plan or small group health plan must have a written internal quality assurance and improvement program that, at a minimum:
(1) provides for ongoing evaluation of the quality of health care provided to its enrollees;
(2) periodically reports the evaluation of the quality of health care to the health carrier's governing body;
(3) follows policies and procedures for the selection and credentialing of network providers that is consistent with community standards;
(4) conducts focused studies directed at problems, potential problems, or areas with potential for improvements in care;
(5) conducts enrollee satisfaction surveys and monitors oral and written complaints submitted by enrollees or members; and
(6) collects and reports Health Effectiveness Data and Information Set (HEDIS) measures and conducts other quality assessment and improvement activities as directed by the commissioner of health.
(b) The commissioner of health shall submit a report to the chairs and ranking minority members of senate and house of representatives committees with primary jurisdiction over commerce and health policy by February 15, 2015, with recommendations for specific quality assurance and improvement standards for all Minnesota health carriers. The recommended standards must not require duplicative data gathering, analysis, or reporting by health carriers.
Subd. 2.
Exemption.
A health carrier that rents a provider network is exempt from this section, 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. 3.
Waiver.
A health carrier that has obtained accreditation through the URAC for network management; quality improvement; credentialing; member protection; and utilization management, or has achieved an excellent or commendable level ranking from the National Committee for Quality Assurance (NCQA), shall be deemed to meet the requirements of subdivision 1. Proof of accreditation must be submitted to the commissioner of health in a form prescribed by the commissioner. The commissioner may adopt rules to recognize similar accreditation standards from any entity recognized by the United States Department of Health and Human Services for accreditation of health insurance issuers or health plans.
Subd. 4.
Enforcement.
The commissioner of health shall enforce this section.
History:
2013 c 84 art 2 s 13,17
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.13 — Service Area Requirements.

62K.13 SERVICE AREA REQUIREMENTS.
(a) Any health carrier that offers an individual or small group health plan, must offer the health plan in a service area that is at least the entire geographic area of a county unless serving a smaller geographic area is necessary, nondiscriminatory, and in the best interest of enrollees. The service area for any individual or small group health plan must be established without regard to racial, ethnic, language, concentrated poverty, or health status-related factors, or other factors that exclude specific high-utilizing, high-cost, or medically underserved populations.
(b) If a health carrier that offers an individual or small group health plan requests to serve less than the entire county, the request must be made to the commissioner of health on a form and manner determined by the commissioner and must provide specific data demonstrating that the service area is not discriminatory, is necessary, and is in the best interest of enrollees.
(c) The commissioner of health shall enforce this section.
History:
2013 c 84 art 2 s 14,17
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.14 — Limited-scope Pediatric Dental Plans.

62K.14 LIMITED-SCOPE PEDIATRIC DENTAL PLANS.
(a) Limited-scope pediatric dental plans must be offered to the extent permitted under the Affordable Care Act: (1) on a guaranteed issue and guaranteed renewable basis; (2) with premiums rated on allowable rating factors used for health plans; and (3) without any exclusions or limitations based on preexisting conditions.
(b) Notwithstanding paragraph (a), a health carrier may discontinue a limited scope pediatric dental plan at the end of a plan year if the health carrier provides written notice to enrollees before coverage is to be discontinued that the particular plan is being discontinued and the health carrier offers enrollees other dental plan options that are the same or substantially similar to the dental plan being discontinued in terms of premiums, benefits, cost-sharing requirements, and network adequacy. The written notice to enrollees must be provided at least 105 days before the end of the plan year.
(c) Limited-scope pediatric dental plans must ensure primary care dental services are available within 60 miles or 60 minutes' travel time.
(d) If a stand-alone dental plan as defined under the Affordable Care Act or a limited-scope pediatric dental plan is offered, either separately or in conjunction with a health plan offered to individuals or small employers, the health plan shall not be considered in noncompliance with the requirements of the essential benefit package in the Affordable Care Act because the health plan does not offer coverage of pediatric dental benefits if these benefits are covered through the stand-alone or limited-scope pediatric dental plan, to the extent permitted under the Affordable Care Act.
(e) Health carriers offering limited-scope pediatric dental plans must comply with this section and sections 62K.07, 62K.08, 62K.13, and 62K.15.
(f) The commissioner of commerce shall enforce paragraphs (a) and (b). Any limited-scope pediatric dental plan that is to be offered to replace a discontinued dental plan under paragraph (b) must be approved by the commissioner of commerce in terms of cost and benefit similarity, and the commissioner of health in terms of network adequacy similarity. The commissioner of health shall enforce paragraph (c).
History:
2013 c 84 art 2 s 15,17
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62K — Minnesota Health Plan Market Rules › Section 62K.15 — Annual Open Enrollment Periods; Special Enrollment Periods.

62K.15 ANNUAL OPEN ENROLLMENT PERIODS; SPECIAL ENROLLMENT PERIODS.
(a) Health carriers offering individual health plans must limit annual enrollment in the individual market to the annual open enrollment periods for MNsure. Nothing in this section limits the application of special or limited open enrollment periods as defined under the Affordable Care Act.
(b) Health carriers offering individual health plans must inform all applicants at the time of application and enrollees at least annually of the open and special enrollment periods as defined under the Affordable Care Act.
(c) Health carriers offering individual health plans must provide a special enrollment period for enrollment in the individual market by employees of a small employer that offers a qualified small employer health reimbursement arrangement in accordance with United States Code, title 26, section 9831(d). The special enrollment period must be available only to employees newly hired by a small employer offering a qualified small employer health reimbursement arrangement, and to employees employed by the small employer at the time the small employer initially offers a qualified small employer health reimbursement arrangement. For employees newly hired by the small employer, the special enrollment period shall last for 30 days after the employee's first day of employment. For employees employed by the small employer at the time the small employer initially offers a qualified small employer health reimbursement arrangement, the special enrollment period shall last for 30 days after the date the arrangement is initially offered to employees.
(d) The commissioner of commerce shall enforce this section.
(e) Health carriers offering individual health plans through MNsure must provide a special enrollment period as required under the easy enrollment health insurance outreach program under section 62V.13.
History:
2013 c 84 art 2 s 16,17; 2013 c 108 art 1 s 67; 1Sp2017 c 6 art 13 s 1; 2023 c 70 art 16 s 6
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.01 — Citation.

62L.01 CITATION.
Subdivision 1.
Popular name.
Sections 62L.01 to 62L.22 may be cited as the "Minnesota Small Employer Health Benefit Act."
Subd. 2.
Jurisdiction.
Sections 62L.01 to 62L.22 apply to any health carrier that offers, issues, delivers, or renews a health benefit plan to a small employer.
Subd. 3.
Legislative findings and purpose.
The legislature finds that underwriting and rating practices in the individual and small employer markets for health coverage create substantial hardship and unfairness, create unnecessary administrative costs, and adversely affect the health of residents of this state. The legislature finds that the premium restrictions provided by this chapter reduce but do not eliminate these harmful effects. Accordingly, the legislature declares its desire to phase out the remaining rating bands as quickly as possible, with the end result of eliminating all rating practices based on risk by July 1, 1997.
History:
1992 c 549 art 2 s 1; 1994 c 625 art 10 s 50
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.04 — Compliance Requirements.

62L.04 COMPLIANCE REQUIREMENTS.
Subdivision 1.
Applicability of chapter requirements.
(a) Beginning July 1, 1993, health carriers participating in the small employer market must offer and make available on a guaranteed issue basis any health benefit plan that they offer, including both of the small employer plans provided in section 62L.05, to all small employers that satisfy the small employer participation and contribution requirements specified in this chapter. Compliance with these requirements is required as of the first renewal date of any small employer group occurring after July 1, 1993. For new small employer business, compliance is required as of the first date of offering occurring after July 1, 1993.
(b) Compliance with these requirements is required as of the first renewal date occurring after July 1, 1994, with respect to employees of a small employer who had been issued individual coverage prior to July 1, 1993, administered by the health carrier on a group basis. Notwithstanding any other law to the contrary, the health carrier shall offer to terminate any individual coverage for employees of small employers who satisfy the small employer participation and contribution requirements specified in section 62L.03 and offer to replace it with a health benefit plan. If the employer elects not to purchase a health benefit plan, the health carrier must offer all covered employees and dependents the option of maintaining their current coverage, administered on an individual basis, or replacement individual coverage. Small employer and replacement individual coverage provided under this subdivision must be without application of underwriting restrictions, provided continuous coverage is maintained.
(c) With respect to small employers having no fewer than 30 nor more than 49 current employees, all dates in this subdivision become July 1, 1995, and any reference to "after" a date becomes "on or after" July 1, 1995.
Subd. 2.
New carriers.
A health carrier entering the small employer market after July 1, 1993, shall begin complying with the requirements of this chapter as of the first date of offering of a health benefit plan to a small employer. A health carrier entering the small employer market after July 1, 1993, is considered to be a member of the health coverage reinsurance association as of the date of the health carrier's initial offer of a health benefit plan to a small employer.
History:
1992 c 549 art 2 s 4; 1993 c 345 art 7 s 6; 1994 c 625 art 10 s 34
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.05 — Small Employer Plan Benefits.

62L.05 SMALL EMPLOYER PLAN BENEFITS.
Subdivision 1.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 2.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 3.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 4.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 4a.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 5.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 6.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 7.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 8.
Continuation coverage.
Small employer plans must include the continuation of coverage provisions required by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Public Law 99-272, as amended, and by state law.
Subd. 9.
Dependent coverage.
Other state law and rules applicable to health plan coverage of newborn infants, dependent children who do not reside with the eligible employee, disabled children and dependents, and adopted children apply to a small employer plan. Health benefit plans that provide dependent coverage must define "dependent" no more restrictively than the definition provided in section 62L.02.
Subd. 10.
Medical expense reimbursement.
Health carriers may reimburse or pay for medical services, supplies, or articles provided under a small employer plan in accordance with the health carrier's provider contract requirements including, but not limited to, salaried arrangements, capitation, the payment of usual and customary charges, fee schedules, discounts from fee-for-service, per diems, diagnosis-related groups (DRGs), and other payment arrangements. Nothing in this chapter requires a health carrier to develop, implement, or change its provider contract requirements for a small employer plan. Coinsurance, deductibles, and out-of-pocket maximums must be calculated and determined in accordance with each health carrier's standard business practices.
Subd. 11.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 12.
[Repealed, 2013 c 84 art 1 s 94]
Subd. 13.
[Repealed, 2013 c 84 art 1 s 94]
History:
1992 c 549 art 2 s 5; 1993 c 247 art 2 s 8; 1993 c 345 art 7 s 7-10; 1994 c 625 art 10 s 35-37; 1999 c 177 s 54; 1999 c 181 s 2,3; 2001 c 215 s 21,22; 1Sp2003 c 14 art 7 s 21; 2005 c 56 s 1; 2008 c 231 s 1; 2010 c 384 s 23; 2012 c 187 art 1 s 12; 2013 c 84 art 1 s 54
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.06 — Disclosure Of Underwriting Rating Practices.

62L.06 DISCLOSURE OF UNDERWRITING RATING PRACTICES.
When offering or renewing a health benefit plan, health carriers shall disclose in all solicitation and sales materials:
(1) provisions concerning the health carrier's right to change premium rates;
(2) provisions relating to renewability of coverage;
(3) the application of any provider network limitations and their effect on eligibility for benefits; and
(4) the ability of small employers to insure eligible employees and dependents currently receiving coverage from the Comprehensive Health Association.
History:
1992 c 549 art 2 s 6; 1994 c 625 art 10 s 38; 2013 c 84 art 1 s 55
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.07 — Small Employer Requirements.

62L.07 SMALL EMPLOYER REQUIREMENTS.
Subdivision 1.
Verification of eligibility.
Health benefit plans must require that small employers offering a health benefit plan maintain information verifying the continuing eligibility of the employer, its employees, and their dependents, and provide the information to health carriers on a quarterly basis or as reasonably requested by the health carrier.
Subd. 2.
Waivers.
Health benefit plans must require that small employers offering a health benefit plan maintain written documentation indicating that each eligible employee was informed of the availability of coverage through the employer and of a waiver of coverage by the eligible employee. This documentation must be provided to the health carrier upon reasonable request.
History:
1992 c 549 art 2 s 7; 1994 c 625 art 10 s 39
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.10 — Supervision By Commissioner.

62L.10 SUPERVISION BY COMMISSIONER.
Subdivision 1.
Reports.
A health carrier doing business in the small employer market shall file by April 1 of each year an annual actuarial opinion with the commissioner certifying that the health carrier complied with the underwriting and rating requirements of this chapter during the preceding year and that the rating methods used by the health carrier were actuarially sound. A health carrier shall retain a copy of the opinion at its principal place of business.
Subd. 2.
Records.
A health carrier doing business in the small employer market shall maintain at its principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
Subd. 3.
Submissions to commissioner.
Subsequent to the annual filing, the commissioner may request information and documentation from a health carrier describing its rating practices and renewal underwriting practices, including information and documentation that demonstrates that a health carrier's rating methods and practices are in accordance with sound actuarial principles and the requirements of this chapter. Except in cases of violations of this chapter or of another chapter, information received by the commissioner as provided under this subdivision is nonpublic.
Subd. 4.
Review of premium rates.
The commissioner shall regulate premium rates charged or proposed to be charged by all health carriers in the small employer market under section 62A.02. The commissioner of health has, with respect to carriers under that commissioner's jurisdiction, all of the powers of the commissioner of commerce under that section.
Subd. 5.
[Repealed, 2013 c 84 art 1 s 94]
History:
1992 c 549 art 2 s 10
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.11 — Penalties And Enforcement.

62L.11 PENALTIES AND ENFORCEMENT.
Subdivision 1.
Disciplinary proceedings.
The commissioner may, by order, suspend or revoke a health carrier's license or certificate of authority and impose a monetary penalty not to exceed $25,000 for each violation of this chapter. Violations include the failure to pay an assessment required by section 62L.22, and knowingly and willfully encouraging a small employer to not meet the contribution or participation requirements of section 62L.03, subdivision 3, in order to avoid the requirements of this chapter. The notice, hearing, and appeal procedures specified in section 60A.052 or 62D.16, as appropriate, apply to the order. The order is subject to judicial review as provided under chapter 14.
Subd. 2.
Enforcement powers.
The commissioners of health and commerce each has for purposes of this chapter all of each commissioner's respective powers under other chapters that are applicable to their respective duties under this chapter.
History:
1992 c 549 art 2 s 11; 1993 c 13 art 2 s 1; 1993 c 345 art 7 s 14
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.15 — Members.

62L.15 MEMBERS.
Subdivision 1.
Annual meeting.
The association shall conduct an annual meeting of the members of the association for the purpose of electing directors and transacting any other appropriate business of the membership of the association. The board shall determine the date, time, and place of the annual meeting. The association shall conduct its first annual member meeting on or before December 1, 1992.
Subd. 2.
Special meetings.
Special meetings of the members must be held whenever called by any three of the directors. At least two categories must be represented among the directors calling a special meeting of the members. The categories are public directors, accident and health insurance companies, nonprofit health service plan corporations, and health maintenance organizations. Special meetings of the members must be held at a time and place designated in the notice of the meeting.
Subd. 3.
Member voting.
Each member's vote is a weighted vote and is based on each member's total insurance premiums, subscriber contract charges, health maintenance contract payments, or other health benefit plan revenue derived from, or on behalf of, small employers during the preceding calendar year, as determined by the board and approved by the commissioner, based on annual statements and other reports considered necessary by the board of directors.
Subd. 4.
Initial member meeting.
At least 60 days before the first annual meeting of the members, the commissioner shall give written notice to all members of the time and place of the member meeting. The members shall elect directors representing the members, approve the initial plan of operation of the association, and transact any other appropriate business of the membership of the association.
Subd. 5.
Member compliance.
All members shall comply with the provisions of this chapter, the association's bylaws, the plan of operation developed by the board of directors, and any other operating, administrative, or other procedures established by the board of directors for the operation of the association. The board may request the commissioner to secure compliance with this chapter through the use of any enforcement action otherwise available to the commissioner.
History:
1992 c 549 art 2 s 15; 1993 c 47 s 9; 1993 c 247 art 2 s 21; 1994 c 465 art 3 s 61
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.18 — Ceding Of Risk.

62L.18 CEDING OF RISK.
Subdivision 1.
Prospective ceding.
For health benefit plans issued on or after July 1, 1993, all health carriers participating in the association may prospectively reinsure an employee or dependent within a small employer group and entire employer groups of seven or fewer eligible employees. A health carrier must determine whether to reinsure an employee or dependent or entire group within 60 days of the commencement of the coverage of the small employer and must notify the association during that time period.
Subd. 2.
Eligibility for reinsurance.
(a) A health carrier may not reinsure existing small employer business through the association. A health carrier may reinsure an employee or dependent who previously had coverage from MCHA who is now eligible for coverage through the small employer group at the time of enrollment as defined in section 62L.03, subdivision 6. A health carrier may not reinsure individuals who have existing individual health care coverage with that health carrier upon replacement of the individual coverage with group coverage as provided in section 62L.04, subdivision 1.
(b) A health carrier may cede to the association the risk of any newly eligible employees or continue to reinsure small employer business for employers who, at the time of renewal of coverage by the same health carrier prior to July 1, 1995, have more than 29 current employees but fewer than 49 current employees. This paragraph is effective retroactively for coverage renewed on or after July 1, 1994.
Subd. 3.
Reinsurance termination.
A health carrier may terminate reinsurance through the association for an employee or dependent or entire group on the anniversary date of coverage for the small employer. If the health carrier terminates the reinsurance, the health carrier may not subsequently reinsure the individual or entire group.
Subd. 4.
Continuing carrier responsibility.
A health carrier transferring risk to the association is completely responsible for administering its health benefit plans. A health carrier shall apply its case management and claim processing techniques consistently between reinsured and nonreinsured business. Small employers, eligible employees, and dependents shall not be notified that the health carrier has reinsured their coverage through the association.
History:
1992 c 549 art 2 s 18; 1995 c 234 art 7 s 23
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.19 — Allowed Reinsurance Benefits.

62L.19 ALLOWED REINSURANCE BENEFITS.
A health carrier may reinsure through the association only those benefits described in section 62L.05. The board may establish guidelines to clarify what coverage is included within the benefits described in this chapter. If a health plan conforms to those benefits as clarified by the board, the benefits are considered to be in accordance with this chapter for purposes of the association's obligations.
History:
1992 c 549 art 2 s 19; 1993 c 47 s 12; 1993 c 247 art 2 s 26
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.21 — Reinsurance Premiums.

62L.21 REINSURANCE PREMIUMS.
Subdivision 1.
Monthly premium.
A health carrier ceding an individual to the reinsurance association shall be assessed a monthly reinsurance coverage premium that is 5.0 times the adjusted average market price. A health carrier ceding an entire group to the reinsurance association shall be assessed a monthly reinsurance coverage premium that is 1.5 times the adjusted average market price. The adjusted average market premium price must be established by the board of directors in accordance with its plan of operation. The board may consider benefit levels in establishing the reinsurance coverage premium.
Subd. 2.
Adjustment of premium rates.
The board of directors shall establish operating rules to allocate adjustments to the reinsurance premium charge of no more than minus 25 percent of the monthly reinsurance premium for health carriers that can demonstrate administrative efficiencies and cost-effective handling of equivalent risks. The adjustment must be made monthly, unless the board provides for a different interval in its operating rules. The operating rules must establish objective and measurable criteria which must be met by a health carrier in order to be eligible for an adjustment. These criteria must include consideration of efficiency attributable to case management, but not consideration of such factors as provider discounts.
Subd. 3.
Liability for premium.
A health carrier is liable for the cost of the reinsurance premium and may not directly charge the small employer for the costs. The reinsurance premium may be reflected only in the rating factors permitted in section 62L.08, as provided in section 62L.08, subdivision 10.
History:
1992 c 549 art 2 s 21; 1994 c 625 art 10 s 48
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62L — Small Employer Insurance Reform › Section 62L.23 — Suspension Of Reinsurance Operations; Reactivation.

62L.23
[Renumbered 62L.08, subd 11]
62L.23 SUSPENSION OF REINSURANCE OPERATIONS; REACTIVATION.
Subdivision 1.
Suspension.
The commissioner may, by order, suspend the operation of sections 62L.13 to 62L.22, upon receipt of a recommendation for suspension from the association board of directors. The order is effective 30 days after publication in the State Register.
Subd. 2.
Suspension of reinsurance operations.
Upon the issuance of an order issued pursuant to subdivision 1, the association shall suspend its operations in an orderly manner supervised by the commissioner and shall provide for the proper storage of the association's records. Notwithstanding the provisions of subdivision 1, the association may continue to levy assessments under section 62L.22 for the purpose of satisfying the association's presuspension expenses and the expenses associated with the association's suspension activities pursuant to this subdivision. The assessments must be approved by the commissioner.
Subd. 3.
No cancellation permitted.
Effective upon the effective date of an order issued pursuant to subdivision 1, reinsurance must be terminated for any person reinsured by the association pursuant to section 62L.18. No health carrier may cancel or fail to renew a health benefit plan for any person whose reinsurance with the association has been terminated subsequently to the issuance of an order pursuant to subdivision 1 solely because of the termination of reinsurance.
Subd. 4.
Reactivation of reinsurance operations.
The commissioner may, by order, reactivate the operation of sections 62L.13 to 62L.22, on a finding that the private market for reinsurance of health benefit plans has failed and that commercial reinsurance is unavailable to health carriers operating in the small employer market in Minnesota. The commissioner may not make findings or issue an order pursuant to this subdivision until a hearing is held pursuant to chapter 14.
Subd. 5.
Transition.
After issuance of any order pursuant to subdivision 4, the commissioner shall immediately appoint an interim board of directors of the association. The terms of members of this interim board must be for a period not to exceed 18 months. The board shall cause the reinsurance operations of the association to be resumed within 180 days of an order issued pursuant to subdivision 4.
Subd. 6.
Modification of five-year rule.
If the commissioner issues an order pursuant to subdivision 4, any health carrier may elect to participate in the reinsurance association, notwithstanding any departicipation by the health carrier within the preceding five years that, pursuant to section 62L.17, would have otherwise prohibited the health carrier's participation.
History:
2001 c 215 s 23
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.01 — Citation, Jurisdiction, And Scope.

62M.01 CITATION, JURISDICTION, AND SCOPE.
Subdivision 1.
Popular name.
This chapter may be cited as the "Minnesota Utilization Review Act of 1992."
Subd. 2.
Jurisdiction.
This chapter applies to any insurance company licensed under chapter 60A to offer, sell, or issue a policy of accident and sickness insurance as defined in section 62A.01; a health service plan licensed under chapter 62C; a health maintenance organization licensed under chapter 62D; the Minnesota Comprehensive Health Association created under chapter 62E; a community integrated service network licensed under chapter 62N; an accountable provider network operating under chapter 62T; a fraternal benefit society operating under chapter 64B; a joint self-insurance employee health plan operating under chapter 62H; a multiple employer welfare arrangement, as defined in section 3 of the Employee Retirement Income Security Act of 1974 (ERISA), United States Code, title 29, section 1103, as amended; a third-party administrator licensed under section 60A.23, subdivision 8, that provides utilization review services for the administration of benefits under a health benefit plan as defined in section 62M.02; any other entity that provides, offers, or administers hospital, outpatient, medical, prescription drug, or other health benefits to individuals treated by a health professional under a policy, plan, or contract; or any entity performing utilization review on behalf of a business entity in this state pursuant to a health benefit plan covering a Minnesota resident.
Subd. 3.
Scope.
(a) Nothing in this chapter applies to review of claims after submission to determine eligibility for benefits under a health benefit plan. The appeal procedure described in section 62M.06 applies to any complaint as defined under section 62Q.68, subdivision 2, that requires a medical determination in its resolution.
(b) This chapter does not apply to managed care plans or county-based purchasing plans when the plan is providing coverage to state public health care program enrollees under chapter 256B or 256L.
History:
1992 c 574 s 1; 1999 c 239 s 3; 2006 c 255 s 31; 2020 c 114 art 1 s 1,2; art 2 s 20
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.03 — Compliance With Standards.

62M.03 COMPLIANCE WITH STANDARDS.
Subdivision 1.
Licensed utilization review organization.
Beginning January 1, 1993, any organization that meets the definition of utilization review organization in section 62M.02, subdivision 21, must be licensed under chapter 60A, 62C, 62D, 62N, 62T, or 64B, or registered under this chapter and must comply with this chapter and section 72A.201, subdivisions 8 and 8a. Each licensed community integrated service network or health maintenance organization that has an employed staff model of providing health care services shall comply with this chapter and section 72A.201, subdivisions 8 and 8a, for any services provided by providers under contract.
Subd. 2.
Nonlicensed utilization review organization.
An organization that meets the definition of a utilization review organization under section 62M.02, subdivision 21, that is not licensed in this state that performs utilization review services for Minnesota residents must register with the commissioner of commerce and must certify compliance with this chapter.
Initial registration must occur no later than January 1, 1993. The registration is effective for two years and may be renewed. Applications for initial and renewal registrations must be made on forms prescribed by the commissioner. Each utilization review organization registered under this chapter shall notify the commissioner of commerce within 30 days of any change in the name, address, or ownership of the organization. The organization shall pay to the commissioner of commerce a fee of $1,000 for the initial registration application and $1,000 for each two-year renewal.
Subd. 3.
Penalties and enforcements.
If a utilization review organization fails to comply with this chapter, the organization may not provide utilization review services for any Minnesota resident. The commissioner of commerce may issue a cease and desist order under section 45.027, subdivision 5, to enforce this provision. The cease and desist order is subject to appeal under chapter 14. A nonlicensed utilization review organization that fails to comply with the provisions of this chapter is subject to all applicable penalty and enforcement provisions of section 72A.201. Each utilization review organization licensed under chapter 60A, 62C, 62D, 62N, 62T, or 64B shall comply with this chapter as a condition of licensure.
History:
1992 c 574 s 3; 1994 c 625 art 2 s 9-11; 1997 c 225 art 2 s 62; 1999 c 239 s 17,18; 2001 c 215 s 24; 2002 c 330 s 27; 2020 c 114 art 2 s 20
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.07 — Prior Authorization Of Services.

62M.07 PRIOR AUTHORIZATION OF SERVICES.
Subdivision 1.
Written standards.
Utilization review organizations conducting prior authorization of services must have written standards that meet at a minimum the following requirements:
(1) written procedures and criteria used to determine whether care is appropriate, reasonable, or medically necessary;
(2) a system for providing prompt notification of its determinations to enrollees and providers and for notifying the provider, enrollee, or enrollee's designee of appeal procedures under clause (4);
(3) compliance with section 62M.05, subdivisions 3a and 3b, regarding time frames for authorizing and making adverse determinations regarding prior authorization requests;
(4) written procedures to appeal adverse determinations of prior authorization requests which specify the responsibilities of the enrollee and provider, and which meet the requirements of sections 62M.06 and 72A.285, regarding release of summary review findings; and
(5) procedures to ensure confidentiality of patient-specific information, consistent with applicable law.
Subd. 2.
Prior authorization of emergency services prohibited.
No utilization review organization, health plan company, or claims administrator may conduct or require prior authorization of emergency confinement or an emergency service. The enrollee or the enrollee's authorized representative may be required to notify the health plan company, claims administrator, or utilization review organization as soon as reasonably possible after the beginning of the emergency confinement or emergency service.
Subd. 3.
Retrospective revocation or limitation of prior authorization.
No utilization review organization, health plan company, or claims administrator may revoke, limit, condition, or restrict a prior authorization that has been authorized unless there is evidence that the prior authorization was authorized based on fraud or misinformation or a previously approved prior authorization conflicts with state or federal law. Application of a deductible, coinsurance, or other cost-sharing requirement does not constitute a limit, condition, or restriction under this subdivision.
Subd. 4.
Submission of prior authorization requests.
If prior authorization for a health care service is required, the utilization review organization, health plan company, or claim administrator must allow providers to submit requests for prior authorization of the health care services without unreasonable delay by telephone, facsimile, or voice mail or through an electronic mechanism 24 hours a day, seven days a week. This subdivision does not apply to dental service covered under MinnesotaCare or medical assistance.
History:
1992 c 574 s 7; 1994 c 485 s 65; 1995 c 234 art 8 s 12; 1999 c 239 s 25; 2004 c 246 s 1; 2016 c 158 art 2 s 22; 2020 c 114 art 1 s 15
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.072 — Use Of Evidence-based Standards.

62M.072 USE OF EVIDENCE-BASED STANDARDS.
If no independently developed evidence-based standards exist for a particular treatment, testing, or imaging procedure, then an insurer or utilization review organization shall not deny coverage of the treatment, testing, or imaging based solely on the grounds that the treatment, testing, or imaging does not meet an evidence-based standard. This section does not prohibit an insurer or utilization review organization from denying coverage for services that are investigational, experimental, or not medically necessary.
History:
2006 c 255 s 32
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.08 — Confidentiality.

62M.08 CONFIDENTIALITY.
Subdivision 1.
Written procedures to ensure confidentiality.
A utilization review organization must have written procedures for ensuring that patient-specific information obtained during the process of utilization review will be:
(1) kept confidential in accordance with applicable federal and state laws;
(2) used solely for the purposes of utilization review, quality assurance, discharge planning, and case management; and
(3) shared only with those organizations or persons that have the authority to receive such information.
Subd. 2.
Summary data.
Summary data is not subject to this section if it does not provide sufficient information to allow identification of individual patients.
History:
1992 c 574 s 8
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.11 — Complaints To Commerce Or Health.

62M.11 COMPLAINTS TO COMMERCE OR HEALTH.
Notwithstanding the provisions of this chapter, an enrollee may file a complaint regarding an adverse determination directly to the commissioner responsible for regulating the utilization review organization.
History:
1992 c 574 s 11; 2020 c 114 art 2 s 15
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.12 — Prohibition Of Inappropriate Incentives.

62M.12 PROHIBITION OF INAPPROPRIATE INCENTIVES.
No individual who is performing utilization review may receive any financial incentive based on the number of adverse determinations made by such individual, provided that utilization review organizations may establish medically appropriate performance standards. This prohibition does not apply to financial incentives established between health plan companies and providers.
History:
1992 c 574 s 12; 1999 c 239 s 30; 2020 c 114 art 2 s 16
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.13 — Severability.

62M.13 SEVERABILITY.
If any provisions of this chapter are held invalid, illegal, or unenforceable for any reason and in any respect, the holding does not affect the validity of the remainder of this chapter.
History:
1992 c 574 s 13; 2020 c 114 art 2 s 20
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.14 — Effect Of Compliance.

62M.14 EFFECT OF COMPLIANCE.
Evidence of a utilization review organization's compliance or noncompliance with the provisions of this chapter shall not be determinative in an action alleging that services denied were medically necessary and covered under the terms of the enrollee's health benefit plan.
History:
1992 c 574 s 14; 2020 c 114 art 2 s 20
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.15 — Applicability Of Other Chapter Requirements.

62M.15 APPLICABILITY OF OTHER CHAPTER REQUIREMENTS.
The requirements of this chapter regarding the conduct of utilization review are in addition to any specific requirements contained in chapter 62A, 62C, 62D, 62Q, 62T, or 72A.
History:
1992 c 574 s 15; 1999 c 239 s 31
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.16 — Rulemaking.

62M.16 RULEMAKING.
If it is determined that rules are reasonable and necessary to accomplish the purpose of this chapter, the rules must be adopted through a joint rulemaking process by both the Department of Commerce and the Department of Health.
History:
1992 c 574 s 16; 2020 c 114 art 2 s 20
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62M — Utilization Review Of Health Care › Section 62M.18 — Annual Posting On Website; Prior Authorizations.

62M.18 ANNUAL POSTING ON WEBSITE; PRIOR AUTHORIZATIONS.
(a) By April 1, 2022, and each April 1 thereafter, a health plan company must post on the health plan company's public website the following data for the immediately preceding calendar year for each commercial product:
(1) the number of prior authorization requests for which an authorization was issued;
(2) the number of prior authorization requests for which an adverse determination was issued and sorted by: (i) health care service; (ii) whether the adverse determination was appealed; and (iii) whether the adverse determination was upheld or reversed on appeal;
(3) the number of prior authorization requests that were submitted electronically and not by facsimile or email or other method pursuant to section 62J.497; and
(4) the reasons for prior authorization denial including but not limited to:
(i) patient did not meet prior authorization criteria;
(ii) incomplete information submitted by the provider to the utilization review organization;
(iii) change in treatment program; and
(iv) the patient is no longer covered by the plan.
(b) All information posted under this section must be written in easily understandable language.
History:
2020 c 114 art 1 s 20
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62N — Community Integrated Service Network › Section 62N.01 — Citation And Purpose.

62N.01 CITATION AND PURPOSE.
Subdivision 1.
Citation.
This chapter may be cited as the "Minnesota Community Integrated Service Network Act."
Subd. 2.
[Repealed, 1997 c 225 art 2 s 63]
History:
1993 c 345 art 1 s 2; 1Sp1993 c 6 s 36; 1994 c 625 art 8 s 33; 1997 c 225 art 2 s 31
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62N — Community Integrated Service Network › Section 62N.02 — Definitions.

62N.02 DEFINITIONS.
Subdivision 1.
Application.
The definitions in this section apply to this chapter.
Subd. 2.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 3.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 4.
Commissioner.
"Commissioner" means the commissioner of health or the commissioner's designated representative.
Subd. 4a.
Community integrated service network or community network.
(a) "Community integrated service network" or "community network" means a formal arrangement licensed by the commissioner under section 62N.25 for providing prepaid health services to enrolled populations of 50,000 or fewer enrollees, including enrollees who are residents of other states.
(b) [Expired]
Subd. 4b.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 4c.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 5.
Enrollee.
"Enrollee" means an individual, including a member of a group, to whom a network is obligated to provide health services under this chapter.
Subd. 6.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 6a.
Health carrier.
"Health carrier" has the meaning given in section 62A.011.
Subd. 7.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 8.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 9.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 10.
[Repealed, 1997 c 225 art 2 s 63]
Subd. 11.
Price.
"Price" means the actual amount of money paid, after discounts or other adjustments, by the person or organization paying money to buy health care coverage and health care services. "Price" does not mean the cost or costs incurred by a network or other entity to provide health care services to individuals.
Subd. 12.
[Repealed, 1997 c 225 art 2 s 63]
History:
1993 c 345 art 1 s 3; 1994 c 625 art 1 s 3,4; art 8 s 34; 1995 c 234 art 1 s 10,11
2023 Minnesota Statutes › Chapters 59A - 79A — Insurance › Chapter 62N — Community Integrated Service Network › Section 62N.22 — Disclosure Of Commissions.

62N.22 DISCLOSURE OF COMMISSIONS.
Before selling any coverage or enrollment in a community integrated service network, a person selling the coverage or enrollment shall disclose in writing to the prospective purchaser the amount of any commission or other compensation the person will receive as a direct result of the sale. The disclosure may be expressed in dollars or as a percentage of the premium. The amount disclosed need not include any anticipated renewal commissions.
History:
1993 c 345 art 1 s 18; 1994 c 625 art 8 s 38; 1997 c 225 art 2 s 32