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S.F. No. 662 - Affordable Care Act Conformity and Health Market Rules (First Engrossment)
 
Author: Senator Tony Lourey
 
Prepared By:
 
Date: March 19, 2013



 

S.F. 662 makes regulatory changes to state law to conform to the Affordable Care Act ("ACA").  S.F. 662 also establishes a work group to report on options for establishing market rules for health carriers offering health plans in the individual and small group markets in Minnesota.

 

Article 1: Affordable Care Act Conformity

Sections 1 and 2 (43A.23, subdivision 1 and 43A.317, subdivision 6) change the definition of dependent child in chapter 43A (state employee group insurance plan).

Section 3 (60A.08, subdivision 15)  requires the commissioner of commerce for all rate increases subject to review that are filed with the commissioner on or after September 1, 2011, to acknowledge receipt of the information; acknowledge that the rate filing is pending review; provide public access to certain information related to the rate increase subject to review; and to provide notice to the public of the review of the proposed rate which states that the public has 30 days to submit written comments to the commissioner on the rate filing.

Sections 4 to 11 (62A.011) add or amend the following definitions in chapter 62A: Affordable Care Act, grandfathered plan, group health plan, health plan, individual health plan, individual market, Minnesota Insurance Marketplace, and qualified health plan.

Section 12 (62A.02, subdivision 8) states that no health plan shall be offered through the Minnesota Insurance Marketplace until a copy of its form and the premium rates pertaining to the form have been filed with the commissioner of commerce and the commissioner has reviewed the health plan for compliance with the certification requirements of the Marketplace.

Section 13 (62A.03, subdivision 1) makes a conforming change to the new definition of dependent children.

Section 14 (62A.04, subdivision 2) make a conforming change with regard to grace periods.  Requires certain health plans that are required to comply with the ACA to include a grace period provision that is no less restrictive than what is required under the ACA.

Section 15 (62A.047) makes a conforming change to this section stating that the policy may not apply preexisting condition limitations to individuals under the age of 19 with the exception of grandfathered plan coverage.

Section 16 (62A.049) removes the failure to obtain prior authorization exception to admissions for treatment of chemical dependency and nervous and mental disorders.

Section 17 (62A.136) makes a technical change removing a section that is being repealed.

Section 18 (62A.149, subdivision 1) removes the ability of an individual to elect to refuse benefits in exchange for an appropriate reduction in premiums or charges under the policy or plan.

Section 19 (62A.17, subdivision 2) specifies individuals age 19 or older in this section (continuation coverage).

Sections 20 and 21 (62A.17, subdivision 6 and 62A.21, subdivision 2b) strike language requiring a health carrier to offer a conversion policy.

Section 22 (62A.28, subdivision 2) modifies the required coverage for scalp hair prosthesis to one per benefit year.

Section 23 (62A.302) specifies the ACA required coverage for dependents.  Requires any health plan that provides dependent coverage of children must make the coverage available until the child reaches the age of 26.

Section 24 (62A.3021) defines dependent for plans other than health plans.

Sections 25 to 29 make conforming changes to 62A.65 (individual market regulation).

Section 25 (62A.615) specifies that a health plan cannot restrict coverage for a preexisting condition for an individual under the age of 19 except under a grandfathered plan.

Section 26 (62A.65, subdivision 3) modifies the premium rate restrictions in accordance with the ACA.  Permits premium rate variations based on age, geographic area, and tobacco use.  Premiums charged shall not be adjusted more frequently than once a year, with the exception of specified changes. Requires a health carrier to consider all enrollees in all health plans offered in the individual market to be members of a single risk pool, with the exception of enrollees in grandfathered plans.   Requires a health carrier to make certain disclosures to be made as part of its solicitation and sales materials.

Section 27 (62A.65, subdivision 5) makes a conforming change in this section that states that no individual health plan may be offered or sold with a preexisting condition limitation or exclusion, with the exception of grandfathered plans.

Section 28 (62A.65, subdivision 6) states that guaranteed issue is required for all health plans issued on or after January 1, 2014, except for grandfathered plans.

Section 29 (62A.65, subdivision 7) strikes unnecessary language with regard to short term coverage counting toward a preexisting condition limitation.

Section 30 (62A.67) creates a new section in chapter 62A that specifies the essential health benefits package required by the ACA.

Subdivision 1 specifies the essential health benefits package, limitations on cost sharing, metal level of coverage, and coverage.

Subdivision 2 requires coverage for enrollees under the age of 21.

Subdivision 3 states the alternative coverage for catastrophic plans.

Subdivision 4 defines essential health benefits.

Sections 31 and 32 (62C) make the necessary conforming changes to chapter 62C (nonprofit health services plan corporations).

Sections 33 to 35 (62D) make the necessary conforming changes to chapter 62D (health maintenance organizations).

Sections 36 to 40 (62E) make the necessary conforming changes to chapter 62E (comprehensive health insurance).

Section 41 (62H.04) states that a joint self insurance plan must comply with the ACA to the extent that it applies to these plans.

Sections 42 to 55 (62L) make conforming changes to the chapter 62L (small employer insurance).

Section 42 (62L.02, subdivision 11) makes a conforming change to the definition of dependent.

Section 43 (62L.02, subdivision 14a) makes a conforming change to the definition of guaranteed issue.

Section 44 (62L.02, subdivision 17a) adds a definition of individual health plan.

Section 45 (62L.02, subdivision 26) changes the definition of small employer to state that a small employer employs at least one, not including a sole proprietor, but no more than 50 employees.

Section 46 (62L.03, subdivision 1) makes conforming change and strikes obsolete language.

Section 47 (62L.03, subdivision 3) specifies that waiver of coverage may include unaffordability as specified under the ACA and provides that this section does not apply to health plans offered through the Minnesota Insurance Marketplace.

Section 48 (62L.03, subdivision 4) makes conforming changes to the underwriting restrictions.

Section 49 (62L.03, subdivision 5) makes a conforming change regarding underwriting restrictions and MCHA enrollees.

Sections 50 and 51 (62L.045) make conforming changes regarding qualified associations.

Section 52 (62L.05, subdivision 10) makes a conforming change to medical expense reimbursement and a reference to maximum lifetime benefits.

Section 53 (62L.06) makes conforming changes to the underwriting rating practices.

Section 54 (62L.08) makes conforming changes to premium rate restrictions.  Permits premium variations based on age, geographic area and tobacco use.

Section 55 (62L.12, subdivision 2) specifies that a health carrier may sell an individual health plan if coverage provided to the small employer is determined to be unaffordable under the ACA.

Sections 56 and 57 (62M) make conforming changes to chapter 62M (utilization review).

Section 56 (62M.05, subdivision 3a) requires the written notification of an initial determination not to certify to be provided in a culturally and linguistically appropriate manner consistent with the ACA.

Section 57 (62M.06, subdivision 1) states that as part of the appeals process for determinations not to certify the utilization review organization must allow the enrollee to review information relied on in the course of the appeal, present evidence and testimony as part of the appeals process and receive continued coverage pending the outcome of the appeals process.

Sections 58 to 88 makes conforming changes to chapter 62Q (health plan companies).

Sections 58 to 65 (62Q.01) add the following definitions to chapter 62Q: Affordable Care Act; grandfathered health plan; group health plan; individual health plan; bone fide association; life threatening condition;  primary care provider;  and dependent child to the limiting age.

Section 66 (62Q.021) requires health plan companies to comply with the ACA.

Section 67 (62Q.17, subdivision 6) strikes language permitting purchasing pools to create tiers within the pool.

Section 68 (62Q.18) states that no health plan company may offer, issue, or sell a health plan that does not make coverage available on a guaranteed issue basis in accordance with the ACA.

Section 69 (62Q.183) contains prohibitions on rescissions of health plans.

Section 70 (62Q.19) includes hospitals or hospital systems specializing in the treatment of children as an essential comunity provider.

Sections 71 and 72 (62Q.23 and 62Q.43) make a conforming change regarding dependent children.

Section 73 (62Q.46) is a new section that sets forth the ACA requirements for preventive items and services.

Subdivision 1

Paragraph (a) defines preventive items and services. 

Paragraph (b) states that a health plan company is prohibited from imposing cost sharing for preventive items and services provided by a participating provider.  Permits a health plan company that has a network of providers to exclude coverage or impose cost sharing for preventive items and services that are delivered by out of network providers.

Paragraph (c) states that a health plan company is not required to cover items or services if the recommendation or guideline is no longer included as a preventive item or service.  A health plan company is required to annually determine whether additional items or services must be covered without cost sharing or whether any items or services are no longer required to be covered.

Paragraph (d) permits a health plan company to use reasonable medical management techniques to determine frequency, method, treatment or setting for a preventive item or service to the extent not specified in a recommendation or guideline.

Paragraph (e) excludes grandfathered plan coverage from this section.

Subdivision 2  

Paragraph (a) permits a health plan company to impose cost sharing with respect to an office visit if a preventive item or service is billed separately or is not tracked separately as individual encounter data from the office visit.

Paragraph (b) prohibits a health plan company from imposing cost sharing with respect to an office visit if the preventive item or service is not billed separately or is not tracked separately from the office visit and the primary purpose of the visit is the delivery of the preventive item or service.

Paragraph (c) permits a health plan company to impose cost sharing with respect to an office visit if a preventive item or service is not billed separately or tracked separately as individual encounter data from the office visit and the primary purpose of the visit is not for the delivery of the preventive item or service.

Subdivision 3 states that a health plan company is not prohibited from providing coverage for items and services in addition to those specified in the ACA.

Section 74 (62Q.47) requires all health plans to meet the requirements of the federal Mental Health Parity Act, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, the ACA, and any amendments or guidance and regulations under those acts.

Section 75 (62Q.52) modifies the section that provides direct access to obstetric and gynecologic services.  Requires the health plan company to treat the provision of obstetrical and gynecological care and the ordering of related items and services by a participating health care professional who specializes in obstetrics or gynecology as the authorization of a primary care health care professional.  The health plan company may require the health care professional to adhere to the health plan company’s policies and procedures including procedures for obtaining prior authorization and for providing services in accordance to a treatment plan approved by the health plan company.

Section 76 (62Q.526) provides the requirements for participation in approved clinical trials.

Section 77 (62Q.55) contains requirements for access to emergency services.

Section 78 (62Q.57) regulates choice of a primary care provider when the health plan provides for designation of one.

Section 79 (62Q.677) contains the prohibitions on lifetime and annual limits.

Sections 80 to 85 (62Q.68-62Q.73) contain conforming changes for complaint resolution, appeals, and external review of adverse determinations.

Section 86 (62Q.75) modifies the definition of a “clean claim”.

Section 87 (62Q.80) is a conforming change related to dependent age.

Section 88 (62Q.81) requires health plans offered by health plan companies  to cover the essential health benefits required by the ACA. Essential health benefits are defined.

Section 89 (62Q.82) requires health plan companies to provide a summary of benefits and coverage explanation as required by the ACA.

Section 90 (72A.20) is a conforming change related to policy limits.

Section 91 (471.61) is a conforming change related to dependents.

Section 92 repeals obsolete statutes.

Article 2: Health Insurance Market Rules Working Group

Section 1 requires the Commissioner of Commerce to convene a working group to study and report on the options available for establishing market rules for the individual and small group market.

 

 

 
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