Requirement to Have "Qualified Plans" on File. 62E.04, Subd 1 & 2.
For each type of qualified plan described in section Minnesota Statute § 62E.06, an insurer or fraternal issuing individual (or group) policies of accident and health insurance in this state, other than group conversion policies, shall develop and file with the commissioner an individual policy which meets the minimum standards of that type of qualified plan. An insurer or fraternal issuing individual (or group) policies of accident and health insurance in this state shall offer each type of qualified plan to each person who applies and is eligible for accident and health insurance from that insurer or fraternal.
♦Mandatory Offer of Major Medical (Qualified) Coverage. 62E.04, Subd 4. Each insurer and fraternal shall affirmatively offer coverage of major medical expenses to every applicant who applies to the insurer or fraternal for a new unqualified policy, which has a lifetime benefit limit of less than $1,000,000, at the time of application and annually to every holder of such an unqualified policy of accident and health insurance renewed by the insurer or fraternal. The coverage shall provide that when a covered individual incurs out-of-pocket expenses of $5,000 or more within a calendar year for services covered in Minnesota Statute § 62E.06, subdivision 1, benefits shall be payable, subject to any co-payment authorized by the commissioner, up to a maximum lifetime limit of not less than $1,000,000. The offer of coverage of major medical expenses may consist of the offer of a rider on an existing unqualified policy or a new policy that is a qualified plan.
Managed Care -- Provider Network Issues
If a PPO Provider Network or Prescription Drug Network is involved please refer to the PPOnetwk Checklist.
Managed Care – Utilization Review Issues
Insurers are subject to the same requirements as licensed utilization review organizations -- Refer to Minnesota Chapter 62M."
60A.06 Kinds of Insurance Permitted
♦60A.08 Contracts of Insurance
Subd 5 Signatures Required
The signatures may be facsimile signatures and may be placed in brackets [] designating a "variable" item.
60A.082 Group Insurance – Benefits Continued (See Minn. Rule
Chapter 2755)
60A.084 Notification on Group Policies
An employer who provides life or health benefits may not change benefits, limit coverage or restrict participation until the certificate holder or
enrollee has been notified.
♦60A.085 Cancellation of Group Coverage; Notification to Covered
Persons
60A.086 Prohibition of Retroactive Termination
61B.28 MN L & H Guaranty Association
Subd 7 Notice Requirement
The L & H Guaranty Notice may be made a part of the application. However, it is not a requirement. It is likely to be made a part of the application, or it could be a freestanding form. It is not a requirement that it be made part of the policy form. The Association address may be placed in brackets [ ] designating a "variable" item.
♦62A.021 Health Care Policy Rates
For filings of Health Plans, as defined in section 62A.011, a 60% loss ratio is required. Insurers must include an actuarial memorandum with the form filing. Refer to Page 14 in this checklist to find the list of Items to be included in Rate Filings for Individual Health Plans and the premium rate restrictions applicable to individual coverage. [M. S. 62A.65, Subd 3]
62A.023 Notice of Rate Change
62A.024 Rate Disclosure
Explanations of rate increase; attribution to statutory changes.
If any health carrier, as defined in section 62A.011, informs a policyholder or contract holder that a rate increase is due to a statutory change, the health carrier must disclose the specific amount of the rate increase
directly due to the statutory change and must identify the specific statutory change. This disclosure must also separate any rate increase due to
medical inflation or other reasons from the rate increase directly due to statutory changes in this chapter, chapter 62C, 62D, 62E, 62H, 62J, 62L, or 64B.
♦62A.03 General Provisions of Policy
Applies to all individual and group policies of accident and sickness insurance as defined in 62A.01, Subd 1. Applies to group coverage, pursuant to Minn. Stat. § 62A.10, Subd 4.
Subd 1 Conditions ♦(1) Premium (2) Time Effective (3) One Person (4) Appearance ♦(5) Description of Policy
The description should include a caption which accurately describes the renewability or cancelability of the policy.
(6) Exceptions in Policy
♦(7) Form Number
Each form, including riders and endorsements, is identified by a form number in the lower left hand corner of the first page thereof.
(8) No Incorporation by Reference
(10) Osteopath, Optometrist, Chiropractor, or Registered Nurse Services
Recognize as a physician, an osteopath, optometrist, chiropractor and RN.
62A.04 Standard Provisions
♦Subd 2 Required Provisions (Applicable to Individual and Group
Coverage)
Applies to group coverage pursuant to Minn. Stat. § 62A.10, Subd 4
Subd 3 Optional Provisions
(11) Narcotics
The optional provision excluding “Narcotics” does not include “Alcohol”.
Subd 10 Return of Premium (Limitation)
A policy of accident and sickness insurance may contain a “return of premium benefit” provided the requirements as specified in this law have been met.
♦62A.041 Maternity Benefits
Maternity benefits are required for group and must be the same for all females whether they are married, unmarried, or a minor.
♦62A.0411 Maternity Care
Maternity benefits must include coverage of a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a cesarean section for a mother and her newborn.
♦62A.042 Family Coverage; Coverage of Newborn Infants
• Notice requirements are prohibited only when such notice is required as a condition for coverage.
• The policy or contract must include as insured or covered family members or dependents any newborn infants immediately from the moment of birth and thereafter which insurance or contract shall provide coverage for illness, injury, congenital malformation, or premature birth.
62A.043 Dental Procedures and Coverage Of Podiatry
Subd 1 Applies To Group & Individual Coverage
Subd 2 Recognizes Physician, Dentist & Podiatrist
If coverage includes services by a dentist or podiatrist, it must provide benefits whether the services are performed by a physician, dentist or podiatrist.
♦Subd 3 Requires Coverage For Surgical & Non-Surgical
Treatment of TMJ Disorder and Craniomandibular Disorder
Coverage must include treatment for TMJ and CMB. Coverage shall be the same as that for treatment to any other joint in the body, and shall apply if the treatment is administered or prescribed by a physician or dentist.
♦62A.044 Payments to Governmental Institutions
Policies may not exclude coverage for services rendered by a hospital or medical institution owned or operated by the federal, state or local government. This includes correctional facilities.
62A.045 Payments on Behalf of Enrollees In Government Health
Programs (Applies Only to Health Plans)
Eligibility for medical programs may not be used as an underwriting guideline or reason for non-acceptance of a risk. Welfare benefits must be secondary to insurance benefits.
62A.046 Coordination of Benefits (Applies Only to Group Coverage)
a) This requirement applies to group contracts providing coverage for hospital and medical treatment or expenses issued or renewed after August 1, 1984.
b) Subdivision 1 provides that an insurer responsible for secondary coverage may not deny coverage or payment of the amount it owes as a secondary pay or on the basis of the failure of another group
contract, which is responsible for primary coverage, to pay for those services.
c) Subdivision 2 provides that direct payments must be made to the provider, custodial parent or DHS for parents who have legal responsibility for a dependent’s medical care.
coverage. Between group and individual plans, group contracts will always be primary.
e) Subdivision 6 does not apply to specified accident, hospital indemnity, specified disease, or other limited benefit insurance policies.
Refer to the Rules For Coordination of Benefits
• COB Rules 2742.0100 – 2742.0500
Coordination of Benefits With Medicare Eligible Individuals.
Policy limitations or exclusionary language that is similar to the following is not in the public interest:
• “If you are eligible for Medicare benefits, but not enrolled, benefits under this Plan will be paid as if you had enrolled for Medicare.” Coordination of Benefits can only occur when the covered person is actually enrolled in Medicare.
♦62A.047 Children's Health Supervision Services And Prenatal Care
Services
Policies must provide coverage for children health services and prenatal care without a deductible, copayment or other coinsurance or dollar limitation requirement. Children health services means pediatric
preventive services including immunizations, developmental assessments and laboratory services from birth to age six.
♦62A.048 Dependent Coverage
(Applicable only to group coverage)
Dependent does not have to reside or have a certain amount of support of the insured to receive benefits.
62A.049 Limitation on Preauthorizations; Emergencies
62A.081 Payments To Facilities Operated By State or Local
Government
♦62A.095 Subrogation
another source unless the health carrier is separately represented by an attorney. If they are represented by an attorney, an agreement regarding allocation may be reached. If an agreement can not be reached, the matter must be submitted to binding arbitration.
Health plans shall not contain subrogation, reimbursement, or provisions containing similar rights to the health carrier issuing the health plan, unless:
• They contain a clause that such subrogation provisions apply only after the covered person has received a full recovery from another source, and
• They contain a clause which provides that the “subrogation” monies which a health carrier may get as a result of a “subrogation right” may be reduced by costs, disbursements, and reasonable attorneys fees, and other expenses incurred obtaining recovery from another source. • A notice requirement on the part of the insured should be emphasized. • Extraneous provisions which this law does not address, need not be
enumerated in the insurance form since the law contains the following statement:
Nothing in this section shall limit a health carrier’s right to recovery from another source which may otherwise exist at law.
If the covered person has an attorney and has accepted monies from his health insurer, then arbitration of allocation disputes between the covered person (or their attorney) and the health carrier’s attorney appears to be mandatory once agreement cannot be reached.
62A.096 Notice To Insurer of Subrogation Claim Required
62A.10 Group Policies
Subd 1 Limitation of The Types of Groups Permitted To Offer
Group Policies
Group insurance policies must meet the definition of “group insurance”. If it is not clear from the file that the group established is one allowed by Minnesota law, the company will be asked to verify that the group is one which is allowed under the following Minnesota statutes.
M. S. § 62A.10 and M. S. § 60A.02, subd., 28 defines five types of associations or trusts to which group coverage may be issued. Briefly, these types are as follows:
• Employers;
• Multiple employer trusts as defined by M. S. § 60A.02, subd. 29; • Trustees of a fund, established or adopted by two or more employers
or maintained for the benefit of members of an association, where officers, members, employees or classes or divisions thereof, may be insured for their individual benefit.
Policy filings for trusts, associations, or other groups that do not meet these statutory qualifications will not be approved.
Subd 4 Applies To Group Coverage
Group forms shall contain the standard provisions applicable to health and accident insurance (refer to M. S. § 62A.04) and shall conform with the other requirements of law relating to the contents and terms of policies of accident and sickness insurance (refer to M. S. § 62A.03) insofar as they may be applicable to group accident and health insurance, and including the other provisions of Subd 4 as appropriate for this type of coverage.
62A.105 Transfers (of Coverage) To Substantially Similar Products
(Applicable only to individual coverage)
62A.14 Handicapped Dependents
Termination upon attainment of a limiting age does not apply to children who are (a) incapable of self-sustaining employment by reason of mental retardation, mental illness or disorder, or physical handicap and (b) chiefly dependent upon the policyholder for support and maintenance. Proof of such incapacity must be furnished to the insurer within 31 days of the child’s attainment of the limiting age and may be required annually after the two-year period following the child’s attainment of the limiting age.
Note: Any notice regarding termination of coverage due to attainment of
the limiting age must include information about this provision. This change is effective August 1, 2003, and applies to all notices regarding termination of coverage due to attainment of the limiting age sent on or after that date. (Chapter 40, Laws of 2003)
♦62A.141 Coverage For Handicapped Dependents
(Applicable only to group coverage)
♦62A.146 Continuation of Benefits To Survivors
(See also Subd. 2 of 62A.21)
62A.148 Group Insurance; Provision of Benefits For Disabled
Employees
♦62A.149 Benefits For Alcoholics and Drug Dependents
Note: Compliance is also required with Minn. Stat. § 62Q.47 for the change and increase in this mandated benefit.
62A.15 Coverage of Certain Licensed Health Professional Services
Subd 1 Applies To Group Policies or Subscriber Contracts
Issued By Accident & Health Insurance Companies
♦Subd 2 Chiropractic Services
Note: Plans which limit the equivalent of chiropractic back treatment to 10 or 15 treatments are in violation of this requirement. Plans which include a PPO component should allow the medically necessary review process to work rather than limiting treatment to 15 treatments.
♦Subd 3 Optometric Services
♦Subd 3(a) Nursing Services "Advanced Nursing Practice"
All benefits relating to expenses incurred for medical treatment or services of a duly licensed physician must include services provided by a registered nurse who is licensed pursuant state law and who is certified by the
profession to engage in advanced nursing practice. "Advanced nursing practice".
Subd 4 Denial of Benefits
No carrier may, in the payment of claims to employees in this state, deny benefits payable for services covered by the policy or contract if the services are lawfully performed by a licensed chiropractor, licensed optometrist, or a registered nurse meeting the requirements of Subdivision 3a.
♦62A.151 Health Insurance Benefits For Emotionally Handicapped
Children
♦62A.152 Benefits For Ambulatory Mental Health Services
Note: Compliance is also required with Minn. Stat. § 62Q.47 for the change and increase in this mandated benefit.
♦62A.153 Outpatient Medical and Surgical Services
62A.154 DES Related Conditions
Policy may not exclude, reduce or limit coverage nor provide for a deductible coinsurance or copayment for treatment related to conditions attributable to diethylstilbestrol or exposure to diethylstilbestrol, unless the insured has be diagnosed as having diethylstilbestrol-related cancer prior to the date coverage for that person begins.
Also, no insurer may surcharge or increase the premium for this condition.
♦62A.155 Coverage For Services Provided To Ventilator-Dependent
Persons
♦62A.17 Termination of or Layoff From Employment; Continuation and
Conversion Rights
♦Subd 1-5 Continuation Requirements and Rights Outlined
New language was added in 2001. Upon request by the terminated or laid off employee, a health carrier must provide the instructions necessary to enable the employee to elect continuation of coverage.
♦Subd 6 Right To Individual Conversion Coverage
62A.18 Disability Offsets Prohibited
Policy may not offset or reduce any benefit due to any increase in
disability benefits received or receivable. The disability benefits referred to are social security benefits, railroad retirement benefits, veteran’s disability benefits, workers’ compensation benefits or any other benefit pursuant to federal or state law.
♦62A.20 Continuation Coverage of Current Spouse And Children
New language was added in 2001. Upon request by the insured or the insured's spouse or dependent child, a health carrier must provide the instructions necessary to enable the spouse or child to elect continuation of coverage.
♦62A.21 Continuation Privileges For Insured Former Spouses And Children
Subd 2(b) Conversion Privilege For Insured Former Spouses And
Children
Please note that the last sentence in subdivision 2a (b) prohibits divorced spouses from being charged a premium greater than "102% of the cost to the plan for such period of coverage for other similarly situated spouses and dependent children with respect to whom the marital relationship has not dissolved...". This means that an additional charge of 2% or 102% may not be charged if a payment is already being made for the cost to the plan for such period of coverage for other similarly situated spouses and dependent children with respect to whom the marital relationship has not dissolved.
New language was added in 2001. Upon request by the insured's former spouse or dependent child, a health carrier must provide the instructions necessary to enable the child or former spouse to elect continuation of coverage.
62A.22 Refusal To Provide Coverage Because of Option Under
Workers' Compensation
♦62A.25 Reconstructive Surgery
(We look for wording that includes that a functional defect as determined by the attending physician is the standard for coverage)
♦62A.26 Coverage For Phenylketonuria Treatment (PKU)
♦62A.265 Coverage For Lyme Disease
♦62A.27 Coverage of Adopted Children
♦62A.28 Coverage For Scalp Hair Prostheses
62A.285 Breast Implants
Policy may not exclude, reduce, or otherwise limit coverage, or contain a deductible, coinsurance or copayment to conditions caused by breast implants. Also an insured may not refuse to issue or renew at the standard rates a policy because the prospective insured has breast implants.
♦62A.30 Coverage For Diagnostic Procedures For Cancer
♦62A.301 Coverage of Full-Time Students
Policies that cover dependents beyond the limiting age based on full-time student status must include in its definition of full-time student, any student who by reason of illness, injury or physical or mental disability as documented by a physician is unable to carry what the educational
institution considers a full-time course load so long as the student’s course load is at least 60% of what otherwise is considered by the institution to be a full-time course load.
Note: Any notice regarding termination of coverage due to attainment of
the limiting age must include information about this provision. This change is effective August 1, 2003, and applies to all notices regarding termination of coverage due to attainment of the limiting age sent on or after that date. (Chapter 40, Laws of 2003)
♦62A.302 Coverage Of Dependents
The definition of dependent can be no more restrictive than that found in Minn. Stat. §62L.02. Minn. Stat. §62L.02 defines a dependent as an eligible employee’s spouse, unmarried child who is under the age of 19 years, unmarried child under the age of 25 years who is a full-time student as defined in section 62A.301, dependent child of any age who is
handicapped and who meets the eligibility criteria in section 62A.14, subd. 2, or any other person whom state or federal law requires to be treated as a dependent for purposes of health plans. For the purpose of this definition, a child includes a child for whom the employee or the employee’s spouse has been appointed legal guardian.
62A.303 Prohibition; Severing of Groups
Insurance agent and/or employer cannot break apart a group by selling employee individual or other health coverage or treat employees or dependents differently.
♦62A.304 Coverage For Port-Wine Stain Elimination
62A.305 Fibrocystic Condition
62A.306 Use of Gender
Premium rate or any other underwriting decision, including initial
issuance, may not be based upon the gender of any person covered or to be covered. In addition, marital status may not be used.
62A.307 Prescription Drugs; Equal Treatment of Prescribers
♦62A.308 Hospitalization and Anesthesia For Dental Procedures
62A.3091 Non-Discriminate Coverage of Tests
62A.3092 Equal Treatment of Surgical First Assisting Services
♦62A.3093 Coverage For Diabetes
62A.60 Retroactive Denial of Expenses
62A.61 Disclosure of Methods Used By Health Carriers To Determine
Usual & Customary Fees
62A.615 Preexisting Conditions Disclosed at Time of Application
62A.64 Health Insurance; Prohibited Agreements
Governs agreements between an insurer and health care providers.
62A.65 Individual Market Regulation
♦Subd 2 Guaranteed Renewal (GR)
Only Guaranteed Renewable Conversion plans are Permanently Guaranteed Renewable pursuant to M. S. 62A.65, Subd. 8.
♦Subd 3 Premium Rate Restrictions Apply to Individual Coverage
(a) Premium rates must be no more than 25 percent above and no more than 25 percent below the index rate charged to individuals for the same or similar coverage, adjusted pro rata for rating periods of less than one year. (b) Premium rates may vary based upon the ages of covered persons only as provided in this paragraph. In addition to the variation permitted under paragraph (a), each health carrier may use an additional premium variation based upon age of up to plus or minus 50 percent of the index rate.
any two regions by more than 20 percent.
(d) Health carriers may use rate cells and must file with the commissioner the rate cells they use.
(e) In developing its index rates and premiums for a health plan, a health carrier shall take into account only the following factors:
• (1) actuarially valid differences in rating factors permitted under paragraphs (a) and (b); and
• (2) actuarially valid geographic variations if approved by the commissioner as provided in paragraph (c).
(f) All premium variations must be justified in initial rate filings and upon request of the commissioner in rate revision filings. All rate variations are subject to approval by the commissioner.
(g) The loss ratio must comply with the section 62A.021 requirements for individual health plans.
(h) The rates must not be approved, unless the commissioner has
determined that the rates are reasonable. In determining reasonableness, the commissioner shall consider the growth rates applied under section 62J.04, subdivision 1, paragraph (b), to the calendar year or years that the proposed premium rate would be in effect, actuarially valid changes in risks associated with the enrollee populations, and actuarially valid changes as a result of statutory changes in Laws 1992, chapter 549.
Checklist of Items to be included in Rate Filings For Individual Health Plans New Rate Sheets
1. Include all information needed to determine all rates charged.
2. Include details on proposed effective date or dates, and how implemented.
General Policy Data
1. Number of Minnesota policyholders and national policyholders.
2. Description of the type of policy, benefits, and general marketing method.
Premium Rate Restrictions
1. Demonstration that the premium restrictions of 62A.65 are met.
2. List of all individual health plan policy forms and date of most recently approved rate filing.
Experience Data
experience is not large enough to be credible.
Rate Increase History
1. Dates that increases actually became effective since 1992.
2. If more than one date per increase, give detail and number of policies affected.
3. Documentation of compliance with annual filing requirement. [62A.021, Subd 1 (c)]
Rate Increase
1. Scope and reason for rate revision.
2. Relationship of proposed rates to current rates, especially noting maximum increase to be seen by any policyholder.
3. Verification of at least 12 months time between rate increases to any policyholder.
4. Support for anticipated claim cost trend.
Loss Ratio Standards
1. The anticipated future loss ratio for the period that rates will be effective, and a description of how it was calculated, including monthly or quarterly
projected earned premiums and incurred claims.
2. A demonstration that the loss ratio standards of Minnesota Statutes 62A.021 are met. Such demonstration may include consideration of:
• The anticipated distribution by policy duration, with expected selection factors.
• Credibility of the Minnesota experience.
• Where credible experience is not available, calculation of expected claim cost based on other sources of credible data.
Certification
Certification by a qualified actuary that, to the best of the actuary's knowledge and judgment, the rate submission is in compliance with the applicable laws and regulations of the state and the benefits are reasonable in relation to the premiums.
Burden of Proof
The party proposing the rate has the burden of proving by a preponderance of the evidence that it does not violate Minnesota Statute 62A.02, Subd. 3.
62A.65 Subd 4 Gender Rating Prohibited
♦Subd 5(a) Portability Requirement For Individual Coverage ♦Subd 5(b) Portability/Conversion Policy Required
• Availability of Portability/Conversion Policy required.
• Coverage for Pregnancy required in Portability/Conversion Policy. • Premium for Portability/Conversion policy set by statute.
Subd 8 Cessation of Individual Business
• Exceptions To Guaranteed Renewal Status
• Guaranteed Renewable plans may be Guaranteed Renewable subject to the health carrier leaving the state by electing to cease doing business in the individual health market as provided by Subd. 8 of 62A.65.
• Only Guaranteed Renewable Conversion plans are Permanently Guaranteed Renewable due to the last sentence of 62A.65, Subd. 8. • Within 30 days after the termination, the health carrier shall submit to the
commissioner a complete list of policyholders that have been terminated. • The termination notice must inform each policyholder of the existence of the Minnesota Comprehensive Health Association, the requirements for being accepted, the procedures for applying for coverage, and the telephone numbers at the department of health and the department of commerce for information about private individual or family health coverage.
♦62E.05 Label of A Qualified/Non-Qualified Plan
62Q.107 Prohibited Provision; Judicial Review
Beginning January 1, 1999, no health plan, including the coverages described in section 62A.011, subdivision 3, clauses (7) and (10), may specify a standard of review upon which a court may review denial of a claim or of any other decision made by a health plan company with respect to an enrollee. This section prohibits limiting court review to a determination of whether the health plan company's decision is arbitrary and capricious, an abuse of discretion, or any other standard less favorable to the enrollee than a preponderance of the evidence.
62Q.12 Denial Of Access
62Q.121 Minnesota Licensed Medical Director For Certain Licensed MN
62Q.137 Chemical Dependency Treatment Covered When Provided By Department of Corrections.
If certain conditions are met, any health plan that provides coverage for chemical dependency treatment must cover chemical dependency treatment provided to an enrollee by the department of corrections while the enrollee is committed to the custody of the commissioner of
corrections following a conviction for a first-degree driving while impaired offense.
EFFECTIVE DATE NOTE: This section, as added by Laws 2001, First
Special Session chapter 9, article 19, section 1, is effective August 1, 2002, and applies to crimes committed on or after that date. Health Plans that will be issued after August 1, 2002 must comply with this new requirement.
62Q.14 Limitation on Restrictions on Enrollee Services.
No health plan company may restrict the choice of an enrollee as to where the enrollee receives services related to:
a) the voluntary planning of the conception and bearing of children, provided that this clause does not refer to abortion services; b) the diagnosis of infertility;
c) the testing and treatment of a sexually transmitted disease; and d) the testing for AIDS or other HIV-related conditions.
This statute addresses where enrollees may receive these four categories of services but only to the extent these categories of services are covered under the enrollee’s contract or certificate of coverage. Nothing in § 62Q.14 should be construed to add benefits not otherwise provided in the enrollee’s contract or certificate of coverage. For example, if the enrollee does not have a prescription drug benefit, this statute does not require the health plan to cover prescription drugs for family planning or treatment of STD.
This statute requires health plan companies to pay for these specific covered health services no matter where enrollees receive these services. There can be no co-payment differential based on where the services are received. Even if the services are received from network,
non-participating providers, the enrollee’s co-payments must be identical to the co-payment that is charged when these services are obtained from
Similarly, for staff model HMOs, the out-of-pocket cost to the enrollee cannot be any more than it would be if these services were obtained from the HMO.
When 62Q.14 services are provided by non-network, non-participating providers, the health plan company must pay billed or actual charges for these services. Payment of less than billed charges may result in the provider billing the enrollee for the balance of the bill. Balance billing will penalize the enrollee for going out of network, effectively restricting the enrollee’s choice as to where these services are received in violation of the clear intent of 62Q.14.
Health plan companies cannot use credentialing requirements to restrict where enrollees choose to receive 62Q.14 services. For example, if health plan companies cover family planning services, than health plan
companies must pay for natural family planning services. Therefore, regardless of where, or from what type of provider, the enrollee receives natural family planning services, the health plan company must pay for these services. However, to the extent any of these services require prior authorization from the health plan company, prior authorization is still allowed under 62Q.14.
For enrollees who have prescription drug coverage, health plan companies must provide full coverage for prescriptions provided in connection with 62Q.14 services, including prescriptions written by network, participating providers and prescriptions dispensed by network, non-participating providers. For example, birth control pills and other birth control devices, Norplant, DepoProvera and prescriptions to treat a sexually transmitted disease, must be covered, if currently covered by the health plan.
Please note that this law is limited to the testing for AIDS and other HIV-related conditions. Therefore, a health plan company could limit its coverage for ongoing treatment to services received from network-participating providers. Similarly, this law is limited to the diagnosis of infertility and does not include ongoing treatment for infertility.
[Administrative Bulletin # 96-2, September 23, 1996]
62Q.16 Mid-Month Termination Prohibited
♦62Q.18 Portability of Group Coverage
♦Subd 7 Portability Of Coverage
(1) make coverage available on a guaranteed issue basis;
(2) give full credit for previous continuous coverage against any applicable preexisting condition limitation or preexisting condition exclusion; and
(3) with respect to a group health plan offered, sold, issued, or renewed to a large employer, impose preexisting condition limitations or preexisting condition exclusions except to the extent that would be permitted under chapter 62L if the group sponsor were a small employer as defined in section 62L.02, subdivision 26.
62Q.181 Written Certification of Coverage.
A health plan company shall provide the written certifications of coverage required under United States Code, title 42, sections 300gg(e) and 300gg-43. This section applies only to coverage that is subject to regulation under state law and only to the extent that the certification of coverage is required under federal law. The commissioner shall enforce this section.
♦62Q.185 Guaranteed Renewability In The Large Employer Group Health
Market
♦62Q.47 Mental Health And Chemical Dependency Services
If coverage is provided for mental health or chemical dependency services, it must be covered the same as any other benefit.
62Q.471 Exclusions For Suicide Attempts Prohibited.
62Q.49 Enrollee Cost Sharing; Negotiated Provider Payments
♦62Q.50 Prostate Cancer Screening
62Q.51 Point-of-Service Option
This section does not apply to a health plan company with fewer than 50,000 enrollees.
♦62Q.52 Direct Access To OB/GYN
♦62Q.527 Coverage Requirement For Nonformulary Drugs For Mental Illness and Emotional Disturbance.
A health plan that provides prescription drug coverage must provide coverage for an antipsychotic drug prescribed to treat emotional
disturbance or mental illness regardless of whether the drug is in the health plan's drug formulary, in the instances as specified in this law.
♦62Q.53 Mental Health Coverage; Minimum Standards For "Medically
Necessary Care"
62Q.535 Coverage Requirement For Court-Ordered Mental Illness and
Emotional Disturbance
Coverage required:
(1) "behavioral care evaluation" The health plan company shall be financially liable for the evaluation if performed by a participating provider of the health plan company...
(2) The health plan company shall be financially liable for treatment described in this law, regardless of whether the provider is in or out of their provider network
(3) All such policies (health plan or otherwise) can not apply a medical necessity test. This court-ordered coverage must not be subject to a separate medical necessity determination by a health plan company under its utilization procedures.
62Q.54 Referrals for Residents of Health Care Facilities
♦62Q.55 Emergency Services
Emergency Medical Care
The definitions for a “medical emergency” may require modification in order to meet the requirements of M. S. 62Q.55. Covered claim situations need not actually be life threatening, as the insurer must take into consideration the requirements of M. S. 62Q.55 in reviewing a denial, or a reduction in coverage of emergency services.
♦62Q.56 Continuity of Care
Plans for continuity of care must be made if a change occurs in health care providers or in changes made by employers.
Subd. 3. Disclosure
included in member contracts or certificates of coverage and must be provided by a health plan company upon request of an enrollee or prospective enrollee.
♦62Q.58 Access to Specialty Care
A health plan company shall establish a procedure by which an enrollee may apply for and, if appropriate, receive a standing referral to a health care provider who is a specialist if a referral to a specialist is required for coverage. This procedure for a standing referral must specify the
necessary managed care review and approval an enrollee must obtain before such a standing referral is permitted.
Subd. 3. Disclosure
Information regarding referral procedures must be included in member contracts or certificates of coverage and must be provided to an enrollee or prospective enrollee by a health plan company upon request.
62Q.65 Access To Provider Discounts
♦62Q.66 Durable Medical Equipment Coverage
♦62Q.67 Disclosure of Covered Durable Medical Equipment
♦62Q.675 Hearing Aids; Persons 18 Years of Age or Younger
A health plan must cover hearing aids for individuals 18 years of age or younger for hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures. Coverage is limited to one hearing aid in each ear every three years. Note: The
effective date is August 1, 2003 and applies to policies, contracts, and certificates issued or renewed on or after that date.
[1st Special Session, Chapter 14, Section 24, Laws of 2003] ♦62Q.68-73 Dispute Resolution Process Requirements
65B.61 Coordination With No-Fault
Subd 3 Rate Reduction If Benefits Coordinated With No-Fault
Auto Payments
72A.139 Use Of Genetic Tests
72A.20 Methods, Acts, And Practices Which Are Defined As Unfair Or
Deceptive
Subd 4(a) Standards For Pre-authorization
Subd 8 (b) and (c) Military Discrimination Prohibited
72A.35 Determination of Health Plan Policy Limits
This provision requires health insurer to calculate when the policy limit is reached based upon actual payments made by the insurer.
♦72A.51 & 72A.52 Right To Cancel (Individual Only)
The caption "RIGHT TO CANCEL” or alternatively acceptable “RIGHT TO EXAMINE AND CANCEL” and the statutory language must be printed on the contract and comply with the statutory time frames for cancellation and return of premium. The printed notice may not be stapled, pinned, or rubber stamped. However, if necessary we will accept a printed sticker which will completely cover the non-compliant language.
Definition of The Term "Investigative"
This "sample" definition has been derived from years of departmental experience in the review of insurance products and our awareness of the potential for dispute or confusion over the coverage of “investigative" treatments as prescribed by the medical practitioner of the insured person. This departmental interpretation has allowed the approval of provisions similar to the following definition. Filings with provisions that are more restrictive must include sufficient justification for such limitations or restrictions in coverage.
a. If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;
b. If reliable evidence shows that the drug, device or medical treatment or procedure is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
drug, device or medical treatment or procedure shall not be considered investigative if reliable evidence shows that its use is reasonable and necessary for the treatment of a particular patient.
Special Wording For Organ Transplants and Services
Health carriers may list certain excluded organ transplants with the organ transplant benefit, provided there is language that these exclusions will be removed due to new technological changes. Below is an example of policy language that historically has been approved by the Department. “As technology changes, the above referenced benefits will be subject to modifications in the form of additions or deletions, when appropriate.”
Exclusionary Provisions Prohibited
Example of objectionable provision:
