Minnesota 2023-2024 Regular Session

Minnesota Senate Bill SF250 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	1.1 A bill for an act
2	2	1.2 relating to health care; requiring health plan companies to develop and implement
3	3	1.3 a shared savings incentive program; requiring a report; proposing coding for new
4	4	1.4 law in Minnesota Statutes, chapter 62Q.
5	5	1.5BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
6	6	1.6 Section 1. [62Q.05] SHARED SAVINGS INCENTIVE PROGRAM.
7	7	1.7 Subdivision 1.Definitions.(a) For purposes of this section, the following terms have
8	8	1.8the meanings given.
9	9	1.9 (b) "Allowed amount" means the contractually agreed upon amount paid for a health
10	10	1.10care service to a health care provider participating in the health plan company's provider
11	11	1.11network. The contractually agreed upon amount includes the amount paid to the provider
12	12	1.12by the health plan company and any cost-sharing required to be paid to the provider by the
13	13	1.13enrollee, including co-payments, deductibles, or coinsurance.
14	14	1.14 (c) "Average" means median or mean.
15	15	1.15 (d) "Commissioner" means the commissioner of health.
16	16	1.16 (e) "Comparable health care service" means a covered nonemergency health care service
17	17	1.17for which a health plan company offers a shared savings incentive payment pursuant to this
18	18	1.18section. Comparable health care services include, at a minimum, health care services within
19	19	1.19the following categories:
20	20	1.20 (1) physical and occupational therapy services;
21	21	1.21 (2) obstetrical and gynecological services;
22	22	1Section 1.
23	23	23-00998 as introduced01/05/23 REVISOR SGS/KA
24	24	SENATE
25	25	STATE OF MINNESOTA
26	26	S.F. No. 250NINETY-THIRD SESSION
27	27	(SENATE AUTHORS: DRAHEIM)
28	28	OFFICIAL STATUSD-PGDATE
29	29	Introduction and first reading01/12/2023
30	30	Referred to Health and Human Services 2.1 (3) radiology and imaging services;
31	31	2.2 (4) laboratory services;
32	32	2.3 (5) infusion therapy services;
33	33	2.4 (6) inpatient and outpatient surgical procedures; and
34	34	2.5 (7) outpatient nonsurgical diagnostic tests and procedures.
35	35	2.6The commissioner may limit what is considered a comparable health care service if a health
36	36	2.7plan company can demonstrate that the allowed amount variation for the service among
37	37	2.8in-network providers is less than $50.
38	38	2.9 (f) "Program" means the shared savings incentive program established by a health plan
39	39	2.10company pursuant to this section.
40	40	2.11 Subd. 2.General.(a) Beginning January 1, 2024, each health plan company offering a
41	41	2.12health plan in this state must offer a shared savings incentive program to its enrollees that
42	42	2.13meets the requirements of this section.
43	43	2.14 (b) Prior to offering the program, a health plan company must file with the commissioner
44	44	2.15a description of the program established by the health plan company pursuant to this section
45	45	2.16in a manner prescribed by the commissioner. The commissioner shall review the filing to
46	46	2.17ensure that the proposed program complies with the requirements of this section.
47	47	2.18 Subd. 3.Cost information website.(a) The commissioner shall develop a web-based
48	48	2.19interactive system for consumers to use to compare provider average charges for health care
49	49	2.20services by procedure or procedure code (CPT code). At a minimum, the health care services
50	50	2.21compared must include the comparable health care services defined under subdivision 1.
51	51	2.22 (b) Charges identified on the website do not constitute a legally binding estimate of the
52	52	2.23allowable charge for or cost to the consumer for the specific health care service, and the
53	53	2.24actual cost of the service may vary based on individual circumstances.
54	54	2.25 (c) The commissioner must contract with a private entity to satisfy the requirements of
55	55	2.26this subdivision.
56	56	2.27 Subd. 4.Shared savings incentive account.A health plan company must establish a
57	57	2.28shared savings incentive account for each enrollee. The health plan company shall deposit
58	58	2.29into the account any incentive payments earned by the enrollee through the program. Funds
59	59	2.30in the account may be withdrawn by the enrollee to pay any applicable co-payments,
60	60	2.31coinsurance, or deductibles. If an enrollee's out-of-pocket maximum has been met for the
61	61	2.32year or there are unused funds in the account at the end of the contract year, the enrollee
62	62	2Section 1.
63	63	23-00998 as introduced01/05/23 REVISOR SGS/KA 3.1may withdraw the funds in the account to pay for premiums for the current contract year or
64	64	3.2the following contract year.
65	65	3.3 Subd. 5.Program requirements.(a) A health plan company must develop and implement
66	66	3.4a shared savings incentive program that provides incentives for an enrollee who receives a
67	67	3.5comparable health care service that is covered under the enrollee's health plan from a health
68	68	3.6care provider that charges less than the average allowed amount paid by that health plan
69	69	3.7company for that health care service. A health plan company may enter into a contract with
70	70	3.8a third-party entity to develop and implement the health plan company's shared savings
71	71	3.9incentive program.
72	72	3.10 (b) The program must provide an enrollee with at least 50 percent of the saved costs for
73	73	3.11each comparable health care service resulting in comparison shopping by the enrollee. A
74	74	3.12health plan company is not required to provide a payment to an enrollee if the health plan
75	75	3.13company's saved cost for a comparable health care service is $25 or less. Compliance with
76	76	3.14this paragraph may be demonstrated in the aggregate of health plans offered by the health
77	77	3.15plan company within the state based on a reasonably anticipated mix of claims.
78	78	3.16 (c) The incentive offered may be calculated as a percentage of the difference in the
79	79	3.17average allowed amount and the price paid or by using another reasonable methodology
80	80	3.18approved by the commissioner. The health plan company shall deposit any incentive earned
81	81	3.19by the enrollee into the enrollee's shared savings incentive account established under
82	82	3.20subdivision 4.
83	83	3.21 (d) A health plan company must determine a process for documenting that the provider
84	84	3.22chosen by an enrollee charges less for a comparable health care service than the average
85	85	3.23allowed amount paid by that health plan company. The health plan company may require
86	86	3.24the enrollee to demonstrate through reasonable documentation, such as a quote from the
87	87	3.25health care provider, that the enrollee comparison shopped prior to receiving care from a
88	88	3.26health care provider that charges less for the comparable health care service than the average
89	89	3.27allowed amount paid by the health plan company.
90	90	3.28 Subd. 6.Allowed amount; disclosure.(a) A health plan company may base the average
91	91	3.29allowed amount paid to an in-network health care provider for a comparable health care
92	92	3.30service on what is paid to an in-network health care provider applicable to the enrollee's
93	93	3.31specific health plan or across all of its health plans offered in the state. A health plan company
94	94	3.32may determine an alternative methodology for calculating the average allowed amount if
95	95	3.33approved by the commissioner.
96	96	3Section 1.
97	97	23-00998 as introduced01/05/23 REVISOR SGS/KA 4.1 (b) A health plan company must establish an interactive mechanism that enables an
98	98	4.2enrollee to request and obtain information from the health plan company on the payments
99	99	4.3made for comparable health care services, as well as quality data. The interactive mechanism
100	100	4.4must allow an enrollee to seek information about the cost of a specific comparable health
101	101	4.5care service in order to compare the average allowed amount paid to in-network health care
102	102	4.6providers based on the enrollee's health plan. The mechanism must also provide a good
103	103	4.7faith estimate of the anticipated charges and out-of-pocket costs an enrollee would be
104	104	4.8responsible to pay for a comparable health care service if provided by an in-network health
105	105	4.9care provider, including any co-payment, deductible, coinsurance or other out-of-pocket
106	106	4.10amount, based on the enrollee's health plan and information available to the health plan
107	107	4.11company at the time the request is made. A health plan company may contract with a
108	108	4.12third-party vendor to satisfy this requirement.
109	109	4.13 (c) A health plan company must inform an enrollee of the enrollee's ability to request
110	110	4.14the average allowed amount paid for a comparable health care service on the health plan
111	111	4.15company's website and in the health plan benefits materials.
112	112	4.16 Subd. 7.Out-of-network provider.(a) If an enrollee elects to receive a comparable
113	113	4.17health care service from an out-of-network provider at a price that is less than the average
114	114	4.18allowed amount paid by the enrollee's health plan company to an in-network provider, then
115	115	4.19the health plan company must allow the enrollee to obtain the health care service from the
116	116	4.20out-of-network provider at the out-of-network provider's price. Upon request of the enrollee,
117	117	4.21the health plan company must apply the payments made by the enrollee for that health care
118	118	4.22service toward the enrollee's deductible and out-of-pocket maximum as specified by the
119	119	4.23enrollee's health plan as if the health care service had been provided by an in-network
120	120	4.24provider. If the enrollee's deductible has been met, the enrollee may submit the claim to the
121	121	4.25health plan company and the health plan company must pay the claim in the same manner
122	122	4.26as claims submitted by an in-network provider.
123	123	4.27 (b) If the enrollee directly pays the out-of-network provider, a health plan company must
124	124	4.28provide a downloadable or interactive online form to the enrollee for submitting proof of
125	125	4.29payment to an out-of-network provider for purposes of administering this subdivision.
126	126	4.30 Subd. 8.Notice to enrollees by health plan company.(a) A health plan company must
127	127	4.31make the program available as a component to any health plan offered by the health plan
128	128	4.32company to a Minnesota resident. Upon enrollment and annually upon renewal, a health
129	129	4.33plan company must provide notice to each enrollee of the availability of the program, a
130	130	4.34description of the incentives available to an enrollee, how an enrollee can earn those
131	131	4.35incentives, and the comparable health care services that may qualify for a shared savings
132	132	4Section 1.
133	133	23-00998 as introduced01/05/23 REVISOR SGS/KA 5.1incentive payment. The notice must inform enrollees of the right to obtain services from a
134	134	5.2different health care provider, regardless of any referral or recommendation made by a
135	135	5.3specific health care provider or entity, and that seeing a different health care provider, either
136	136	5.4the health care provider to which the referral was made or a different health care provider,
137	137	5.5may result in an incentive to the enrollee if the enrollee follows the steps set by the enrollee's
138	138	5.6health plan company.
139	139	5.7 (b) The health plan company must also provide this information on the health plan
140	140	5.8company's website.
141	141	5.9 Subd. 9.Notice to enrollee by provider.Health care providers must post in a visible
142	142	5.10area notification of a patient's ability, for those with individual or small group coverage, to
143	143	5.11obtain a description of the service or the applicable standard medical codes or current
144	144	5.12procedural terminology codes sufficient to allow a health plan company to assist the patient
145	145	5.13in comparing out-of-pocket and contracted amounts paid for the patient's care to different
146	146	5.14health care providers for similar services. The notification must notify the patient that the
147	147	5.15patient's health plan company is required to provide enrollees with an estimate of the
148	148	5.16out-of-pocket costs and the average allowed amount paid for the patient's care. A health
149	149	5.17care provider may provide additional information to a patient that informs the patient of
150	150	5.18specific price transparency mechanisms or websites that may be available to the patient.
151	151	5.19 Subd. 10.No administrative expense.A shared savings incentive payment made by a
152	152	5.20health plan company according to this section is not an administrative expense of the health
153	153	5.21plan company for purposes of rate development or rate filing and may be considered a
154	154	5.22medical expense for purposes of medical loss ratio requirements.
155	155	5.23 Subd. 11.Exclusions.This section does not apply to health plans offered to enrollees
156	156	5.24who are enrolled in a public health care program under chapter 256B or 256L.
157	157	5.25 Subd. 12.Report.(a) By March 1 of each year, beginning March 1, 2025, a health plan
158	158	5.26company must file with the commissioner for the previous calendar year:
159	159	5.27 (1) the total number of shared savings incentive payments made pursuant to this section;
160	160	5.28 (2) the use of comparable health care services by category of service for which shared
161	161	5.29savings incentive payments were made;
162	162	5.30 (3) the average amount of shared savings incentive payments made by category of
163	163	5.31service;
164	164	5.32 (4) the total savings achieved below the average prices by category of service; and
165	165	5Section 1.
166	166	23-00998 as introduced01/05/23 REVISOR SGS/KA 6.1 (5) the total number and percentage of the health plan company's enrollees who
167	167	6.2participated in the program.
168	168	6.3 (b) By April 15 of each year, beginning April 15, 2025, the commissioner of health shall
169	169	6.4submit an aggregate report containing the information submitted under paragraph (a) by
170	170	6.5the health plan companies to the chairs and ranking minority members of the legislative
171	171	6.6committees with jurisdiction over health insurance.
172	172	6.7 Subd. 13.Citation.This section may be cited as the "Patient Right To Shop Act."
173	173	6Section 1.
174	174	23-00998 as introduced01/05/23 REVISOR SGS/KA