1.1 A bill for an act
1.2 relating to health care; requiring health plan companies to develop and implement
1.3 a shared savings incentive program; requiring a report; proposing coding for new
1.4 law in Minnesota Statutes, chapter 62Q.
1.5BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.6 Section 1. [62Q.05] SHARED SAVINGS INCENTIVE PROGRAM.
1.7 Subdivision 1.Definitions.(a) For purposes of this section, the following terms have
1.8the meanings given.
1.9 (b) "Allowed amount" means the contractually agreed upon amount paid for a health
1.10care service to a health care provider participating in the health plan company's provider
1.11network. The contractually agreed upon amount includes the amount paid to the provider
1.12by the health plan company and any cost-sharing required to be paid to the provider by the
1.13enrollee, including co-payments, deductibles, or coinsurance.
1.14 (c) "Average" means median or mean.
1.15 (d) "Commissioner" means the commissioner of health.
1.16 (e) "Comparable health care service" means a covered nonemergency health care service
1.17for which a health plan company offers a shared savings incentive payment pursuant to this
1.18section. Comparable health care services include, at a minimum, health care services within
1.19the following categories:
1.20 (1) physical and occupational therapy services;
1.21 (2) obstetrical and gynecological services;
1Section 1.
23-00998 as introduced01/05/23 REVISOR SGS/KA
SENATE
STATE OF MINNESOTA
S.F. No. 250NINETY-THIRD SESSION
(SENATE AUTHORS: DRAHEIM)
OFFICIAL STATUSD-PGDATE
Introduction and first reading01/12/2023
Referred to Health and Human Services 2.1 (3) radiology and imaging services;
2.2 (4) laboratory services;
2.3 (5) infusion therapy services;
2.4 (6) inpatient and outpatient surgical procedures; and
2.5 (7) outpatient nonsurgical diagnostic tests and procedures.
2.6The commissioner may limit what is considered a comparable health care service if a health
2.7plan company can demonstrate that the allowed amount variation for the service among
2.8in-network providers is less than $50.
2.9 (f) "Program" means the shared savings incentive program established by a health plan
2.10company pursuant to this section.
2.11 Subd. 2.General.(a) Beginning January 1, 2024, each health plan company offering a
2.12health plan in this state must offer a shared savings incentive program to its enrollees that
2.13meets the requirements of this section.
2.14 (b) Prior to offering the program, a health plan company must file with the commissioner
2.15a description of the program established by the health plan company pursuant to this section
2.16in a manner prescribed by the commissioner. The commissioner shall review the filing to
2.17ensure that the proposed program complies with the requirements of this section.
2.18 Subd. 3.Cost information website.(a) The commissioner shall develop a web-based
2.19interactive system for consumers to use to compare provider average charges for health care
2.20services by procedure or procedure code (CPT code). At a minimum, the health care services
2.21compared must include the comparable health care services defined under subdivision 1.
2.22 (b) Charges identified on the website do not constitute a legally binding estimate of the
2.23allowable charge for or cost to the consumer for the specific health care service, and the
2.24actual cost of the service may vary based on individual circumstances.
2.25 (c) The commissioner must contract with a private entity to satisfy the requirements of
2.26this subdivision.
2.27 Subd. 4.Shared savings incentive account.A health plan company must establish a
2.28shared savings incentive account for each enrollee. The health plan company shall deposit
2.29into the account any incentive payments earned by the enrollee through the program. Funds
2.30in the account may be withdrawn by the enrollee to pay any applicable co-payments,
2.31coinsurance, or deductibles. If an enrollee's out-of-pocket maximum has been met for the
2.32year or there are unused funds in the account at the end of the contract year, the enrollee
2Section 1.
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
3.2the following contract year.
3.3 Subd. 5.Program requirements.(a) A health plan company must develop and implement
3.4a shared savings incentive program that provides incentives for an enrollee who receives a
3.5comparable health care service that is covered under the enrollee's health plan from a health
3.6care provider that charges less than the average allowed amount paid by that health plan
3.7company for that health care service. A health plan company may enter into a contract with
3.8a third-party entity to develop and implement the health plan company's shared savings
3.9incentive program.
3.10 (b) The program must provide an enrollee with at least 50 percent of the saved costs for
3.11each comparable health care service resulting in comparison shopping by the enrollee. A
3.12health plan company is not required to provide a payment to an enrollee if the health plan
3.13company's saved cost for a comparable health care service is $25 or less. Compliance with
3.14this paragraph may be demonstrated in the aggregate of health plans offered by the health
3.15plan company within the state based on a reasonably anticipated mix of claims.
3.16 (c) The incentive offered may be calculated as a percentage of the difference in the
3.17average allowed amount and the price paid or by using another reasonable methodology
3.18approved by the commissioner. The health plan company shall deposit any incentive earned
3.19by the enrollee into the enrollee's shared savings incentive account established under
3.20subdivision 4.
3.21 (d) A health plan company must determine a process for documenting that the provider
3.22chosen by an enrollee charges less for a comparable health care service than the average
3.23allowed amount paid by that health plan company. The health plan company may require
3.24the enrollee to demonstrate through reasonable documentation, such as a quote from the
3.25health care provider, that the enrollee comparison shopped prior to receiving care from a
3.26health care provider that charges less for the comparable health care service than the average
3.27allowed amount paid by the health plan company.
3.28 Subd. 6.Allowed amount; disclosure.(a) A health plan company may base the average
3.29allowed amount paid to an in-network health care provider for a comparable health care
3.30service on what is paid to an in-network health care provider applicable to the enrollee's
3.31specific health plan or across all of its health plans offered in the state. A health plan company
3.32may determine an alternative methodology for calculating the average allowed amount if
3.33approved by the commissioner.
3Section 1.
23-00998 as introduced01/05/23 REVISOR SGS/KA 4.1 (b) A health plan company must establish an interactive mechanism that enables an
4.2enrollee to request and obtain information from the health plan company on the payments
4.3made for comparable health care services, as well as quality data. The interactive mechanism
4.4must allow an enrollee to seek information about the cost of a specific comparable health
4.5care service in order to compare the average allowed amount paid to in-network health care
4.6providers based on the enrollee's health plan. The mechanism must also provide a good
4.7faith estimate of the anticipated charges and out-of-pocket costs an enrollee would be
4.8responsible to pay for a comparable health care service if provided by an in-network health
4.9care provider, including any co-payment, deductible, coinsurance or other out-of-pocket
4.10amount, based on the enrollee's health plan and information available to the health plan
4.11company at the time the request is made. A health plan company may contract with a
4.12third-party vendor to satisfy this requirement.
4.13 (c) A health plan company must inform an enrollee of the enrollee's ability to request
4.14the average allowed amount paid for a comparable health care service on the health plan
4.15company's website and in the health plan benefits materials.
4.16 Subd. 7.Out-of-network provider.(a) If an enrollee elects to receive a comparable
4.17health care service from an out-of-network provider at a price that is less than the average
4.18allowed amount paid by the enrollee's health plan company to an in-network provider, then
4.19the health plan company must allow the enrollee to obtain the health care service from the
4.20out-of-network provider at the out-of-network provider's price. Upon request of the enrollee,
4.21the health plan company must apply the payments made by the enrollee for that health care
4.22service toward the enrollee's deductible and out-of-pocket maximum as specified by the
4.23enrollee's health plan as if the health care service had been provided by an in-network
4.24provider. If the enrollee's deductible has been met, the enrollee may submit the claim to the
4.25health plan company and the health plan company must pay the claim in the same manner
4.26as claims submitted by an in-network provider.
4.27 (b) If the enrollee directly pays the out-of-network provider, a health plan company must
4.28provide a downloadable or interactive online form to the enrollee for submitting proof of
4.29payment to an out-of-network provider for purposes of administering this subdivision.
4.30 Subd. 8.Notice to enrollees by health plan company.(a) A health plan company must
4.31make the program available as a component to any health plan offered by the health plan
4.32company to a Minnesota resident. Upon enrollment and annually upon renewal, a health
4.33plan company must provide notice to each enrollee of the availability of the program, a
4.34description of the incentives available to an enrollee, how an enrollee can earn those
4.35incentives, and the comparable health care services that may qualify for a shared savings
4Section 1.
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
5.2different health care provider, regardless of any referral or recommendation made by a
5.3specific health care provider or entity, and that seeing a different health care provider, either
5.4the health care provider to which the referral was made or a different health care provider,
5.5may result in an incentive to the enrollee if the enrollee follows the steps set by the enrollee's
5.6health plan company.
5.7 (b) The health plan company must also provide this information on the health plan
5.8company's website.
5.9 Subd. 9.Notice to enrollee by provider.Health care providers must post in a visible
5.10area notification of a patient's ability, for those with individual or small group coverage, to
5.11obtain a description of the service or the applicable standard medical codes or current
5.12procedural terminology codes sufficient to allow a health plan company to assist the patient
5.13in comparing out-of-pocket and contracted amounts paid for the patient's care to different
5.14health care providers for similar services. The notification must notify the patient that the
5.15patient's health plan company is required to provide enrollees with an estimate of the
5.16out-of-pocket costs and the average allowed amount paid for the patient's care. A health
5.17care provider may provide additional information to a patient that informs the patient of
5.18specific price transparency mechanisms or websites that may be available to the patient.
5.19 Subd. 10.No administrative expense.A shared savings incentive payment made by a
5.20health plan company according to this section is not an administrative expense of the health
5.21plan company for purposes of rate development or rate filing and may be considered a
5.22medical expense for purposes of medical loss ratio requirements.
5.23 Subd. 11.Exclusions.This section does not apply to health plans offered to enrollees
5.24who are enrolled in a public health care program under chapter 256B or 256L.
5.25 Subd. 12.Report.(a) By March 1 of each year, beginning March 1, 2025, a health plan
5.26company must file with the commissioner for the previous calendar year:
5.27 (1) the total number of shared savings incentive payments made pursuant to this section;
5.28 (2) the use of comparable health care services by category of service for which shared
5.29savings incentive payments were made;
5.30 (3) the average amount of shared savings incentive payments made by category of
5.31service;
5.32 (4) the total savings achieved below the average prices by category of service; and
5Section 1.
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
6.2participated in the program.
6.3 (b) By April 15 of each year, beginning April 15, 2025, the commissioner of health shall
6.4submit an aggregate report containing the information submitted under paragraph (a) by
6.5the health plan companies to the chairs and ranking minority members of the legislative
6.6committees with jurisdiction over health insurance.
6.7 Subd. 13.Citation.This section may be cited as the "Patient Right To Shop Act."
6Section 1.
23-00998 as introduced01/05/23 REVISOR SGS/KA