Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Definitions.
The terms used in this part have the meanings given
them.
A. "Supplemental benefit" means
an addition to the comprehensive health maintenance services required to be
offered under a health maintenance contract which provides coverage for
nonemergency, self-referred medical services which is either a comprehensive
supplemental benefit or a limited supplemental benefit according to items B and
C.
B. "Comprehensive supplemental
benefit" means supplemental benefits for at least 80 percent of the usual and
customary charges for all covered supplemental benefits, except emergency care,
required for a qualified plan as provided by Minnesota Statutes, section
62E.06,
or a qualified Medicare supplement plan as provided by Minnesota Statutes,
section
62E.07,
if it were offered as a separate health insurance policy.
C. "Limited supplemental benefit" means any
supplemental benefit which provides coverage at a lower level of benefits than
a comprehensive supplemental benefit as described under item B. A limited
supplemental benefit may be for a single service or any combination of
services.
Subp. 2.
General requirements on provisions of coverage.
A. Every contract or evidence of coverage for
supplemental benefits must clearly state that supplemental benefits are not
used to fulfill comprehensive health maintenance services requirements as
defined under part 4685.0700.
B. In
any supplemental benefit providing coverage for a medical service,
reimbursement for that service must include treatments by all credentialed
practitioners providing that service within the lawful scope of their practice,
unless the certificate of coverage specifically states the practitioners whose
services are not covered. Practitioners described in item C cannot be excluded
from coverage. For the purposes of this part, "credentialed practitioners"
means any practitioner licensed or registered according to Minnesota Statutes,
chapter 214.
C. In any supplemental
benefit providing reimbursement for any service which is in the lawful scope of
practice of a duly licensed osteopath, optometrist, chiropractor, or registered
nurse meeting the requirements of Minnesota Statutes, section
62A.15,
subdivision 3a, the person entitled to benefits is entitled to access to that
service on an equal basis, whether the service is performed by a physician,
osteopath, optometrist, chiropractor, or registered nurse meeting the
requirements of Minnesota Statutes, section
62A.15,
subdivision 3a, licensed under the laws of Minnesota.
D. A health maintenance organization may not
deny supplemental benefit coverage of a service which the enrollee has already
received solely on the basis of lack of prior authorization or second opinion,
to the extent that the service would otherwise have been covered under the
member's supplemental benefits contract by the health maintenance organization
had prior authorization or second opinion been obtained.
A health maintenance organization may, however, impose a
reasonable assessment on coverage for lack of prior authorization or second
opinion for supplemental benefit services. The assessment cannot exceed 20
percent of the usual and customary charges for the service received.
Subp. 3.
Disclosure of comprehensive supplemental benefits.
Every contract or evidence of coverage for comprehensive
supplemental benefits must include a detailed explanation of the services
available, including:
A. that coverage
is available for all benefits provided by the health maintenance organization's
health maintenance services, except emergency services;
B. the level of coverage available under the
supplemental benefits, including any limitations on benefits;
C. all applicable copayments, deductibles, or
maximum lifetime benefits;
D. the
procedure for any required preauthorization, including any applicable
assessment for failure to obtain preauthorization; and
E. the procedure for filing claims under the
supplemental benefits, which must comply with Minnesota Statutes, section
72A.201.
Subp. 4.
Disclosure of
limited supplemental benefits.
Every contract or evidence of coverage for limited
supplemental benefits must include a detailed explanation of the services
available including:
A. A listing of
all benefits available through the limited supplemental benefits.
B. A listing of any excluded general grouping
of services as listed in Minnesota Statutes, section
62D.02, subdivision
7. Those groupings include preventive health services, outpatient health
services, and inpatient hospital and physician services. Emergency care is not
permitted as a supplemental benefit.
If less than all of the services in a grouping are covered,
specific exclusions within that grouping must be clearly stated.
C. The level of coverage available
for each benefit.
D. All applicable
copayments, deductibles, or maximum lifetime benefits.
E. The procedure for any required
preauthorization, including any applicable assessment for failure to obtain
preauthorization.
F. The procedure
for filing claims under the limited supplemental benefits, which must comply
with Minnesota Statutes, section
72A.201.
Subp. 5.
Consumer
information.
All supplemental benefits evidences of coverage and contracts
must contain a clear and complete statement of enrollees' rights as consumers.
The statement must be in bold print and captioned "Important Consumer
Information For Supplemental Benefits" and must include the provisions given in
this subpart for either comprehensive or limited supplemental benefits, as
appropriate.
If the supplemental benefit is presented as a separate
section of a contract or evidence of coverage for comprehensive health
maintenance services, the supplemental benefit section must begin with the
consumer information statement described in this subpart.
If the supplemental benefit is presented as an integrated
part of the comprehensive health maintenance services contract or evidence of
coverage, the consumer information statement must appear directly after the
"Enrollee Bill Of Rights" and "Consumer Information" sections at the beginning
of the contract or evidence of coverage. When the supplemental benefits are
integrated into the contract or evidence of coverage, the differences between
the supplemental benefit and the comprehensive health maintenance services must
be clearly set out in the contract or evidence of coverage.
The statement of consumer information must be in the language
of item A or B, as appropriate, or in substantially similar language (to
accommodate changes based on a prior authorization requirement, for example)
approved in advance by the commissioner:
A. CONSUMER INFORMATION FOR COMPREHENSIVE
SUPPLEMENTAL BENEFITS
(1) COVERED SERVICES:
The comprehensive supplemental benefit of (name of health maintenance
organization) covers similar services as the comprehensive health maintenance
services, but at a different level of coverage. Copayments, deductibles, and
maximum lifetime benefit restrictions may apply. Your contract describes the
procedures for receiving coverage through the comprehensive supplemental
benefit.
(2) PROVIDERS: To receive
services through the comprehensive supplemental benefit, you may go to
providers of covered services who are not on the provider list supplied by
(name of health maintenance organization) and for whom you did not get a
referral.
(3) REFERRALS: A referral
from (name of health maintenance organization) for services covered by the
comprehensive supplemental benefit is not required to receive coverage.
However, if a referral is requested from (name of health maintenance
organization) you may be eligible for the same services, from the same provider
at a lower cost to you, as a benefit under your comprehensive health
maintenance services. See section (section number) of the evidence of coverage
for specific referral details.
(4)
PRIOR AUTHORIZATION: You are not required to get prior authorization from (name
of health maintenance organization) before using supplemental benefits.
However, there may be a reduction in the level of benefits available to you if
you do not get prior authorization. See section (section number) of your
comprehensive supplemental benefit agreement for specific information about
prior authorization.
(5)
EXCLUSIONS: Coverage of supplemental benefits is limited to those services
specified in your evidence of coverage. Section (specify number) lists related
services which are excluded from coverage and clarifies any limitations imposed
on coverage of the services.
(6)
CONTINUATION: Your comprehensive health maintenance services contract provides
for continuation and conversion rights under certain circumstances. If you
continue your coverage as an individual under your group contract, the
comprehensive supplemental benefits will also continue. If you convert to an
individual plan, supplemental benefits may not be available. Your continuation
and conversion rights to supplemental benefits are explained fully in your
comprehensive supplemental benefits agreement.
(7) DISCONTINUATION: Your comprehensive
supplemental benefits are an addition to your comprehensive health maintenance
coverage. Changes in your contract may result in the discontinuation of one or
more of your supplemental benefits. Please read all amendments to your contract
carefully.
B. CONSUMER
INFORMATION FOR LIMITED SUPPLEMENTAL BENEFITS
(1) COVERED SERVICES: The limited
supplemental benefit of (name of health maintenance organization) covers
selected services, at varying levels of coverage. It does not provide coverage
from nonparticipating providers for all services which are covered under a
qualified health insurance plan under Minnesota law. Copayments, deductibles,
and maximum lifetime benefit restrictions may apply. Your certificate of
coverage lists the services available and describes the procedures for
receiving coverage through the limited supplemental benefit.
(2) PROVIDERS: To receive benefits through
the limited supplemental benefit, you may go to providers of covered services
who are not on the provider list supplied by (name of health maintenance
organization) and for whom you did not get a referral.
(3) REFERRALS: A referral from (name of
health maintenance organization) for services covered by the limited
supplemental benefit is not required to receive coverage. However, if a
referral is requested from (name of health maintenance organization) you may be
eligible for the same services, from the same provider at a lower cost to you,
as a benefit under your comprehensive health maintenance services. See section
(section number) of the evidence of coverage for specific referral
details.
(4) PRIOR AUTHORIZATION:
You are not required to get prior authorization from (name of health
maintenance organization) before using supplemental benefits. However, there
may be a reduction in the level of benefits available to you if you do not get
prior authorization. See section (section number) of your limited supplemental
benefit agreement for specific information about prior authorization.
(5) EXCLUSIONS: Services are not covered by
the limited supplemental benefit unless they are listed in the supplemental
benefits provisions. Section (specify number) lists related services which are
excluded from coverage and clarifies any limitations imposed on coverage of
such services.
(6) CONTINUATION:
Your comprehensive health maintenance services contract provides for
continuation and conversion rights under certain circumstances. If you continue
your coverage as an individual under your group contract, the limited
supplemental benefits will also continue. If you convert to an individual plan,
supplemental benefits may not be available. Your continuation and conversion
rights to supplemental benefits are explained fully in your limited
supplemental benefits agreement.
(7) DISCONTINUATION: Your limited
supplemental benefits are an addition to your comprehensive health maintenance
coverage. Changes in your contract may result in the discontinuation of one or
more of your supplemental benefits. Please read all amendments to your contract
carefully.
Subp.
6.
Out-of-pocket expenditures.
The out-of-pocket expenses associated with supplemental
benefits, including any deductibles, copayments, or assessments shall be
included in the total out-of-pocket expenses for the entire package of benefits
provided. The total out-of-pocket expenses for a plan, including those
associated with supplemental benefits, may not exceed the maximum out-of-pocket
expenses allowable for a number three qualified insurance plan as provided by
Minnesota Statutes, section
62E.06.
A plan may designate what portion of the maximum
out-of-pocket benefits may be used in relation to supplemental benefits, with
the remaining amount applicable only to comprehensive health maintenance
services. For example, if the maximum out-of-pocket expenses is $3,000, the
health maintenance organization may designate in its contract that the maximum
out-of-pocket expenses for supplemental benefits is $1,000 and the maximum for
comprehensive health maintenance services is $2,000. Every contract and
evidence of coverage must include a clear statement describing the maximum
out-of-pocket expense limitations and, if applicable, how the maximum expenses
are allocated between comprehensive health maintenance services and
supplemental benefits. The contract must also include a statement explaining
that enrollees must keep track of their own out-of-pocket expenses, provided
however, that enrollees may contact the health maintenance organization member
services department for assistance in determining the amount paid by the
enrollee for specific services received.
Subp. 7.
Annual reports.
A health maintenance organization which offers supplemental
benefits shall include in its annual report the following schedules:
A. a schedule analyzing the previous year's
estimation of incurred but not reported supplemental benefit claims;
and
B. a schedule detailing claim
development including historical data.
Subp. 8.
Estimation of incurred but not
reported claims.
A health maintenance organization must estimate incurred but
not reported supplemental benefit claim liabilities according to generally
accepted actuarial methods.
Appropriate claim expense reserves are required with respect
to the estimated expense of settlement of all incurred but not reported
supplemental benefit claims. All such reserves for prior years shall be tested
for adequacy and reasonableness by reviewing the health maintenance
organization's claim runoff schedules in accordance with generally accepted
accounting principles and reported annually in the schedule required under
subpart 7, item A.
Subp. 9.
Accrued supplemental benefit claims.
NAIC BLANK FOR HEALTH MAINTENANCE ORGANIZATIONS, REPORT #1-B:
Report#1-B: BALANCE SHEET LIABILITIES AND NET WORTH is amended by adding a line
for Accrued Supplemental Benefit Claims, and requiring a separate schedule of
such claims detailing direct claims adjusted or in the process of adjustment
plus incurred but not reported claims.
Statutory Authority: MS s
62D.05;
62D.20
