Subdivision 1. Essential health benefits package. (a) Health plan companies offering individual and small group health plans must include the essential health benefits package required under section 1302(a) of the Affordable Care Act and as described in this subdivision.
(b) The essential health benefits package means coverage that:
(1) provides essential health benefits as outlined in the Affordable Care Act;
(2) limits cost-sharing for such coverage in accordance with the Affordable Care Act, as described in subdivision 2; and
(3) subject to subdivision 3, provides bronze, silver, gold, or platinum level of coverage in accordance with the Affordable Care Act.
Subd. 2. Coverage for enrollees under the age of 21. If a health plan company offers health plans in any level of coverage specified under section 1302(d) of the Affordable Care Act, as described in subdivision 1, paragraph (b), clause (3), the health plan company shall also offer coverage in that level to individuals who have not attained 21 years of age as of the beginning of a policy year.
Subd. 3. Alternative compliance for catastrophic plans. A health plan company that does not provide an individual or small group health plan in the bronze, silver, gold, or platinum level of coverage, as described in subdivision 1, paragraph (b), clause (3), shall be treated as meeting the requirements of section 1302(d) of the Affordable Care Act with respect to any policy year if the health plan company provides a catastrophic plan that meets the requirements of section 1302(e) of the Affordable Care Act.
Subd. 4. Essential health benefits; definition. For purposes of this section, "essential health benefits" has the meaning given under section 1302(b) of the Affordable Care Act and includes:
(1) ambulatory patient services;
(2) emergency services;
(3) hospitalization;
(4) laboratory services;
(5) maternity and newborn care;
(6) mental health and substance use disorder services, including behavioral health treatment;
(7) pediatric services, including oral and vision care;
(8) prescription drugs;
(9) preventive and wellness services and chronic disease management;
(10) rehabilitative and habilitative services and devices; and
(11) additional essential health benefits included in the EHB-benchmark plan, as defined under the Affordable Care Act.
Subd. 5. Exception. This section does not apply to a dental plan described in section 1311(d)(2)(B)(ii) of the Affordable Care Act.
Subd. 6. Prescription drug benefits. (a) A health plan company that offers individual health plans must ensure that, in each geographic area the health plan company services, no fewer than one silver plan and one gold plan the health plan company offers apply a predeductible, flat-dollar amount co-payment structure to the entire drug benefit, including all tiers.
(b) A health plan company that offers small group health plans must ensure that, in each geographic area the health plan company services, no fewer than one silver plan and one gold plan the health plan company offers apply a predeductible, flat-dollar amount co-payment structure to the entire drug benefit, including all tiers.
(c) The highest allowable co-payment for the highest cost drug tier for health plans offered pursuant to this subdivision must be no greater than 1/12 of the plan's out-of-pocket maximum for an individual.
(d) The flat-dollar amount co-payment tier structure for prescription drugs under this subdivision must be graduated and proportionate.
(e) All individual and small group health plans offered pursuant to this subdivision must be:
(1) clearly and appropriately named to aid the purchaser in the selection process;
(2) marketed in the same manner as other health plans offered by the health plan company; and
(3) offered for purchase to any individual or small group.
(f) This subdivision does not apply to catastrophic plans, grandfathered plans, large group health plans, health savings accounts, qualified high deductible health benefit plans, limited health benefit plans, or short-term limited-duration health insurance policies.
(g) A health plan company or a pharmacy benefit manager, as defined in section 62W.02, subdivision 15, must not delay or divide payment to a pharmacy or pharmacy provider, as defined in section 62W.02, subdivision 14, because of the co-payment structure of a health plan offered pursuant to this subdivision.
(h) Health plan companies must meet the requirements in this subdivision separately for plans offered through MNsure under chapter 62V and plans offered outside of MNsure.
(i) Notwithstanding section 62A.65, subdivision 2, a health plan company may discontinue offering a health plan under this subdivision if, three years after the date the silver or gold health plan is initially offered, the silver or gold health plan has fewer than 75 enrollees enrolled in the plan. A health plan company discontinuing a plan under this paragraph must only discontinue the silver or gold health plan that has fewer than 75 enrollees and:
(1) provide notice of the plan's discontinuation in writing, in a form prescribed by the commissioner, to each individual enrolled in the plan at least 90 calendar days before the date the coverage is discontinued;
(2) offer on a guaranteed issue basis to each individual enrolled the option to purchase an individual health plan currently being offered by the health plan company for individuals in that geographic rating area. An enrollee who does not select an option must be automatically enrolled in the individual health plan closest in actuarial value to the enrollee's current plan; and
(3) act uniformly without regard to any health status-related factor of enrolled individuals or dependents of enrolled individuals who may become eligible for coverage.
(j) A health plan company must annually report to the commissioner, as specified by the commissioner, the total enrollment in silver and gold plans under this subdivision.
2013 c 84 art 1 s 89; 2022 c 44 s 4
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.