Subdivision 1. Applicability and scope. Except as provided in subdivision 2, this section applies to a health plan company providing coverage under an individual or group health plan. For purposes of this section, essential health benefits is defined under section 62Q.81.
Subd. 2. Grandfathered plan limits. (a) The prohibition on lifetime limits applies to grandfathered plans providing individual health plan coverage or group health plan coverage.
(b) The prohibition and limits on annual limits apply to grandfathered plans providing group health plan coverage, but do not apply to grandfathered plans providing individual health plan coverage.
Subd. 3. Prohibition on lifetime and annual limits. (a) Except as provided in subdivisions 4 and 5, a health plan company offering coverage under an individual or group health plan shall not establish a lifetime limit on the dollar amount of essential health benefits for any individual.
(b) Except as provided in subdivisions 4, 5, and 6, a health plan company shall not establish any annual limit on the dollar amount of essential health benefits for any individual.
Subd. 4. Nonessential benefits; out-of-network providers. (a) Subdivision 3 does not prevent a health plan company from placing annual or lifetime dollar limits for any individual on specific covered benefits that are not essential health benefits as defined in section 62Q.81, subdivision 4, to the extent that the limits are otherwise permitted under applicable federal or state law.
(b) Subdivision 3 does not prevent a health plan company from placing an annual or lifetime limit for services provided by out-of-network providers.
Subd. 5. Excluded benefits. This section does not prohibit a health plan company from excluding all benefits for a given condition.
Subd. 6. Annual limits prior to January 1, 2014. For plan or policy years beginning before January 1, 2014, for any individual, a health plan company may establish an annual limit on the dollar amount of benefits that are essential health benefits provided the limit is no less than the following:
(1) for a plan or policy year beginning after September 22, 2010, but before September 23, 2011, $750,000;
(2) for a plan or policy year beginning after September 22, 2011, but before September 23, 2012, $1,250,000; and
(3) for a plan or policy year beginning after September 22, 2012, but before January 1, 2014, $2,000,000.
In determining whether an individual has received benefits that meet or exceed the allowable limits, a health plan company shall take into account only essential health benefits.
Subd. 7. Waivers. For plan or policy years beginning before January 1, 2014, a health plan is exempt from the annual limit requirements if the health plan is approved for a waiver from the requirements by the United States Department of Health and Human Services, but the exemption only applies for the specified period of time that the waiver from the United States Department of Health and Human Services is applicable.
Subd. 8. Notices. (a) At the time a health plan company receives a waiver from the United States Department of Health and Human Services, the health plan company shall notify prospective applicants and affected policyholders and the commissioner in each state where prospective applicants and any affected insured are known to reside.
(b) At the time the waiver expires or is otherwise no longer in effect, the health plan company shall notify affected policyholders and the commissioner in each state where any affected insured is known to reside.
Subd. 9. Reinstatement. A health plan company shall comply with all provisions of the Affordable Care Act with regard to reinstatement of coverage for individuals whose coverage or benefits under a health plan ended by reason of reaching a lifetime dollar limit on the dollar value of all benefits for the individual.
Subd. 10. Compliance. This section does not require compliance with any provision of the Affordable Care Act before the effective date provided for that provision in the Affordable Care Act. The commissioner shall enforce this section.
2013 c 84 art 1 s 80
Structure Minnesota Statutes
Chapters 59A - 79A — Insurance
Chapter 62Q — Health Plan Companies
Section 62Q.02 — Applicability Of Chapter.
Section 62Q.021 — Federal Act; Compliance Required.
Section 62Q.025 — High Deductible Health Plans.
Section 62Q.03 — Process For Risk Adjustment System.
Section 62Q.075 — Local Public Accountability And Collaboration Plan.
Section 62Q.096 — Credentialing Of Providers.
Section 62Q.097 — Requirements For Timely Provider Credentialing.
Section 62Q.101 — Evaluation Of Provider Performance.
Section 62Q.1055 — Chemical Dependency.
Section 62Q.106 — Dispute Resolution By Commissioner.
Section 62Q.107 — Prohibited Provision; Judicial Review.
Section 62Q.12 — Denial Of Access.
Section 62Q.121 — Licensure Of Medical Directors.
Section 62Q.135 — Contracting For Chemical Dependency Services.
Section 62Q.137 — Chemical Dependency Treatment; Coverage.
Section 62Q.14 — Restrictions On Enrollee Services.
Section 62Q.145 — Abortion And Scope Of Practice.
Section 62Q.16 — Midmonth Termination Prohibited.
Section 62Q.165 — Universal Coverage.
Section 62Q.17 — Voluntary Purchasing Pools.
Section 62Q.18 — Portability Of Coverage.
Section 62Q.181 — Written Certification Of Coverage.
Section 62Q.184 — Step Therapy Override.
Section 62Q.1841 — Prohibition On Use Of Step Therapy For Metastatic Cancer.
Section 62Q.185 — Guaranteed Renewability; Large Employer Group.
Section 62Q.186 — Prohibition On Rescissions Of Health Plans.
Section 62Q.188 — Flexible Benefits Plans.
Section 62Q.19 — Essential Community Providers.
Section 62Q.22 — Health Care Services Prepaid Option.
Section 62Q.23 — General Services.
Section 62Q.32 — Local Ombudsperson.
Section 62Q.33 — Local Government Public Health Functions.
Section 62Q.37 — Audits Conducted By Independent Organization.
Section 62Q.43 — Geographic Access.
Section 62Q.45 — Coverage For Out-of-area Primary Care.
Section 62Q.46 — Preventive Items And Services.
Section 62Q.47 — Alcoholism, Mental Health, And Chemical Dependency Services.
Section 62Q.471 — Exclusion For Suicide Attempts Prohibited.
Section 62Q.472 — Screening And Testing For Opioids.
Section 62Q.48 — Cost-sharing In Prescription Insulin Drugs.
Section 62Q.49 — Enrollee Cost Sharing; Negotiated Provider Payments.
Section 62Q.50 — Prostate Cancer Screening.
Section 62Q.51 — Point-of-service Option.
Section 62Q.52 — Direct Access To Obstetric And Gynecologic Services.
Section 62Q.521 — Postnatal Care.
Section 62Q.525 — Coverage For Off-label Drug Use.
Section 62Q.526 — Coverage For Participation In Approved Clinical Trials.
Section 62Q.527 — Nonformulary Antipsychotic Drugs; Required Coverage.
Section 62Q.528 — Drug Coverage In Emergency Situations.
Section 62Q.529 — Coverage For Drugs Prescribed And Dispensed By Pharmacies.
Section 62Q.53 — Mental Health Coverage; Medically Necessary Care.
Section 62Q.535 — Coverage For Court-ordered Mental Health Services.
Section 62Q.54 — Referrals For Residents Of Health Care Facilities.
Section 62Q.545 — Coverage Of Home Care Nursing.
Section 62Q.55 — Emergency Services.
Section 62Q.556 — Unauthorized Provider Services.
Section 62Q.56 — Continuity Of Care.
Section 62Q.57 — Designation Of Primary Care Provider.
Section 62Q.58 — Access To Specialty Care.
Section 62Q.645 — Efficiency Reports And Distribution Of Information.
Section 62Q.65 — Access To Provider Discounts.
Section 62Q.66 — Durable Medical Equipment Coverage.
Section 62Q.67 — Disclosure Of Covered Durable Medical Equipment.
Section 62Q.675 — Hearing Aids; Persons 18 Or Younger.
Section 62Q.676 — Medication Therapy Management.
Section 62Q.677 — Lifetime And Annual Limits.
Section 62Q.678 — Dependent Child Notice.
Section 62Q.69 — Complaint Resolution.
Section 62Q.70 — Appeal Of The Complaint Decision.
Section 62Q.71 — Notice To Enrollees.
Section 62Q.72 — Record Keeping; Reporting.
Section 62Q.73 — External Review Of Adverse Determinations.
Section 62Q.731 — Appeal From Adverse Determination.
Section 62Q.733 — Definitions.
Section 62Q.735 — Provider Contracting Procedures.
Section 62Q.736 — Payment Rates.
Section 62Q.737 — Service Code Changes.
Section 62Q.739 — Unilateral Terms Prohibited.
Section 62Q.74 — Network Shadow Contracting.
Section 62Q.746 — Access To Certain Information Regarding Providers.
Section 62Q.75 — Prompt Payment Required.
Section 62Q.751 — Collecting Deductibles And Coinsurance.
Section 62Q.77 — Terms Of Coverage Disclosure.
Section 62Q.78 — Dental Benefit Plan Requirements.
Section 62Q.80 — Community-based Health Care Coverage Program.
Section 62Q.81 — Essential Health Benefit Package Requirements.