HF 3757

as introduced - 91st Legislature (2019 - 2020) Posted on 03/26/2020 01:12pm

A bill for an act
relating to health; determining payment parameters for emergency services;
amending Minnesota Statutes 2018, section 62Q.556.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2018, section 62Q.556, is amended to read:

62Q.556 UNAUTHORIZED PROVIDER SERVICES.

Subdivision 1.

Unauthorized provider services.

deleted text begin (a) Except as provided in paragraph
(c), deleted text end Unauthorized provider services occur when an enrollee receives deleted text begin services deleted text end :

new text begin (1) emergency services as defined under section 62Q.55, subdivision 3, from a
nonparticipating provider, hospital, or other facility;
new text end

deleted text begin (1) deleted text end new text begin (2) services new text end from a nonparticipating provider at a participating hospital or ambulatory
surgical center deleted text begin , when the services are rendered: deleted text end new text begin ; or
new text end

deleted text begin (i) due to the unavailability of a participating provider;
deleted text end

deleted text begin (ii) by a nonparticipating provider without the enrollee's knowledge; or
deleted text end

deleted text begin (iii) due to the need for unforeseen services arising at the time the services are being
rendered; or
deleted text end

deleted text begin (2) deleted text end new text begin (3) services new text end from a participating provider that sends a specimen taken from the
enrollee in the participating provider's practice setting to a nonparticipating laboratory,
pathologist, or other medical testing facility.

deleted text begin (b) Unauthorized provider services do not include emergency services as defined in
section 62Q.55, subdivision 3.
deleted text end

deleted text begin (c) The services described in paragraph (a), clause (2), are not unauthorized provider
services if the enrollee gives advance written consent to the provider acknowledging that
the use of a provider, or the services to be rendered, may result in costs not covered by the
health plan.
deleted text end

Subd. 2.

Prohibition.

(a) An enrollee's financial responsibility for the unauthorized
provider services shall be the same cost-sharing requirements, including co-payments,
deductibles, coinsurance, coverage restrictions, and coverage limitations, as those applicable
to services received by the enrollee from a participating provider. A health plan company
must apply any enrollee cost sharing requirements, including co-payments, deductibles, and
coinsurance, for unauthorized provider services to the enrollee's annual out-of-pocket limit
to the same extent payments to a participating provider would be applied.

new text begin (b) A provider, hospital, laboratory, or other facility shall not bill the enrollee for
unauthorized provider services for an amount greater than the enrollee's financial
responsibility as determined under paragraph (a).
new text end

deleted text begin (b) deleted text end new text begin (c) new text end A health plan company must attempt to negotiate the reimbursement, less any
applicable enrollee cost sharing under paragraph (a), for the unauthorized provider services
with the nonparticipating provider. If a health plan company's and nonparticipating provider's
attempts to negotiate reimbursement for the health care services do not result in a resolution,
the health plan company or provider may elect to refer the matter for binding arbitration,
chosen in accordance with paragraph deleted text begin (c) deleted text end new text begin (d) new text end . A nondisclosure agreement must be executed
by both parties prior to engaging an arbitrator in accordance with this section. The cost of
arbitration must be shared equally between the parties.

deleted text begin (c) deleted text end new text begin (d) new text end The deleted text begin commissioner deleted text end new text begin commissioners new text end of health new text begin and commerce new text end , in consultation with
the commissioner of the Bureau of Mediation Services, must develop a list of professionals
qualified in arbitration, for the purpose of resolving disputes between a health plan company
and nonparticipating provider arising from the payment for unauthorized provider services.
The commissioner of health shall publish the list on the Department of Health website, and
update the list as appropriate.

deleted text begin (d) deleted text end new text begin (e) new text end The arbitrator must consider relevant information, including the health plan
company's payments to other nonparticipating providers for the same services, the
circumstances and complexity of the particular case, and the usual and customary rate for
the service based on information available in a database in a national, independent,
not-for-profit corporation, and similar fees received by the provider for the same services
from other health plans in which the provider is nonparticipating, in reaching a decision.

new text begin Subd. 3. new text end

new text begin Annual data reporting. new text end

new text begin (a) Beginning April 1, 2021, a health plan company
must report annually to the commissioner:
new text end

new text begin (1) the total number of claims and total billed and paid amount for unauthorized provider
services, by service and provider type, submitted to the health plan in the prior calendar
year;
new text end

new text begin (2) the total number of claims and total billed and paid amount for unauthorized provider
services, by service and provider type, submitted for binding arbitration pursuant to
subdivision 2, paragraph (c), in the prior calendar year; and
new text end

new text begin (3) the total number of enrollee complaints received regarding unauthorized provider
services in the prior calendar year.
new text end

new text begin (b) The commissioners of commerce and health may develop a format for health plan
companies to comply with paragraph (a).
new text end

new text begin Subd. 4. new text end

new text begin Enforcement. new text end

new text begin (a) Any provider licensed under chapter 144 or 147 is subject
to the requirements of this section.
new text end

new text begin (b) The commissioner of commerce or health may enforce this section. If the
commissioner of health has cause to believe that any hospital or facility licensed under
chapter 144 has violated this section, the commissioner may investigate, examine, and
otherwise enforce this section pursuant to chapter 144 or may refer the potential violation
to the relevant licensing board with regulatory authority over the provider.
new text end

new text begin (c) If the Minnesota Board of Medical Practice has cause to believe that a provider has
violated this section it may further investigate and enforce the provisions of this section
pursuant to chapter 214.
new text end