COMPREHENSIVE MAJOR MEDICAL CHECKLIST FOR CODE 34

Transcription

1 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 Subd 3 Limitation On Combination Policies Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 1 OF 23

2 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 60A.085 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. Cancellation of Group Coverage; Notification to Covered Persons 60A.086 Prohibition of Retroactive Termination 61B.28 MN L & H Guaranty Association 62A.021 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. 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 A health insurer or service plan corporation must send written notice to its policyholders and contract holders at their last known address at least 30 days in advance of the effective date of a proposed rate change. This notice requirement does not apply to individual certificate holders covered by group insurance policies or group subscriber contracts. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 2 OF 23

3 62A.024 Rate Disclosure 62A.03 Subd 1 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. 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. 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 (9) Medical benefits Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 3 OF 23

4 (10) Osteopath, Optometrist, Chiropractor, or Registered Nurse Services Recognize as a physician, an osteopath, optometrist, chiropractor and RN. 62A.04 Standard Provisions 62A A A.042 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. Maternity Benefits Maternity benefits are required for group and must be the same for all females whether they are married, unmarried, or a minor. 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. 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. The coverage must include benefits for inpatient or outpatient expenses arising from medical and dental treatment up to age 18, including orthodontic and oral surgery treatment, involved in the management of birth defects known as cleft lip and cleft palate. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 4 OF 23

5 62A.043 Dental Procedures and Coverage Of Podiatry Subd 1 Applies To Group & Individual Coverage 62A.044 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. 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, 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. d) Subdivision 6 provides that coordinated benefits must provide 100 % Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 5 OF 23

6 62A A.048 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 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. 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. 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 A subrogation clause must prove that subrogation only occurs after the insured has received a full recovery from another source. A subrogation clause must also provide that the health carrier s subrogation right is subject to subtraction for actual monies paid to account for the pro rata share of the covered person s costs, disbursements, and reasonable attorney fees, and other expenses incurred in obtaining the recovery from Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 6 OF 23

7 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; Purchasing pools as described in M. S. 62Q.17; Any association as defined by M. S. 60A.02; Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 7 OF 23

8 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 62A.141 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) Coverage For Handicapped Dependents (Applicable only to group coverage) Handicapped dependents must be added to a policy without preexisting condition limitations, insurability, eligibility, or health underwriting approval. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 8 OF 23

9 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 62A.151 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. Health Insurance Benefits For Emotionally Handicapped Children Not applicable to individual (non-group) coverage. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 9 OF 23

10 62A A.153 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. Outpatient Medical and Surgical Services 62A.154 DES Related Conditions 62A.155 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. 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 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 62A.20 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. Continuation Coverage of Current Spouse And Children New language was added in 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. (See also Subd. 2 of 62A.21) Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 10 OF 23

11 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 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 62A.26 62A A.27 62A.28 Reconstructive Surgery (We look for wording that includes that a functional defect as determined by the attending physician is the standard for coverage) Coverage For Phenylketonuria Treatment (PKU) Coverage For Lyme Disease Coverage of Adopted Children 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. Insurer may not refuse to provide or renew coverage because the insured has an option to elect workers compensation coverage. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 11 OF 23

12 62A.30 Coverage For Diagnostic Procedures For Cancer 62A A.302 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) 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 62A.304 Insurance agent and/or employer cannot break apart a group by selling employee individual or other health coverage or treat employees or dependents differently. Coverage For Port-Wine Stain Elimination 62A.305 Fibrocystic Condition No health plan shall be terminated, canceled, nonrenewed, or contain any increased premium rate, or exclusion, reduction, or limitation on benefits, nor shall coverage be denied, solely because the covered person has been diagnosed as having a Fibrocystic breast condition. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 12 OF 23

13 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. (c) A health carrier may request approval by the commissioner to establish no more than three geographic regions and to establish separate index rates for each region, provided that the index rates do not vary between Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 13 OF 23

14 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 Premium and claim experience for the last five years in Minnesota, as well as aggregate experience to date for the lifetime of the block. Include earned premiums, incurred claims, and earned/incurred loss ratios. Both Minnesota only and nationwide experience must be provided, if the Minnesota Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 14 OF 23

15 experience is not large enough to be credible. Rate Increase History 1. Dates that increases actually became effective since 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 A.65 Subd 4 Gender Rating Prohibited [End of Checklist of Items to be included in Rate Filings for Individual Health Plans] Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 15 OF 23

16 62E.05 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. 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 Health Carriers. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 16 OF 23

17 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 non-network, nonparticipating providers, the enrollee s co-payments must be identical to the co-payment that is charged when these services are obtained from network, participating providers. For health plans with more than one tier of benefits, the enrollee s co-payment must be assessed at the tier 1 level (the highest level of coverage). Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 17 OF 23

18 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 non-network, nonparticipating providers and prescriptions dispensed by non-network, nonparticipating 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 HIVrelated conditions. Therefore, a health plan company could limit its coverage for ongoing treatment to services received from networkparticipating 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 Upon termination of a person s health coverage, the insurer must provide coverage until the end of the month. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 18 OF 23

19 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 Q.181 Written Certification of Coverage. 62Q Q.47 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. Guaranteed Renewability In The Large Employer Group Health Market 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 62Q.52 This section does not apply to a health plan company with fewer than 50,000 enrollees. Direct Access To OB/GYN 62Q.525 Coverage For Off Label Drug Use Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 19 OF 23

20 62Q Q.53 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. 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 62Q.56 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. 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 Information regarding an enrollee's rights under this section must be Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 20 OF 23

21 62Q.58 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. 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 62Q.67 Durable Medical Equipment Coverage 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 Dispute Resolution Process Requirements 65B.61 Coordination With No-Fault Subd 3 Rate Reduction If Benefits Coordinated With No-Fault Auto Payments Regarding the coordination with no-fault; please note the following: When a policy coordinates with "no-fault" medical benefit, an actuarial memorandum indicating and supportive of the rate reduction (usually 1% or more) must be provided for compliance with Subdivision 3 of 65B.61. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 21 OF 23

22 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 c. If the use of the drug, device or medical treatment or procedure is not medically necessary. However, for purposes of this subparagraph c., a Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 22 OF 23

23 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: A provision that excludes coverage for Services with a poor prognosis (likelihood of success), as determined by the insurance company. The form must be modified to set forth the outside standards upon which denial will be based rather than the arbitrary phrase -- as determined by (the insurer). Additionally, denial of services with a poor prognosis is not a denial that is in the public interest. Prior Editions -- July 10, 2003, August 22, 2002, April 18, 2002 PAGE 23 OF 23