HF 638

as introduced - 91st Legislature (2019 - 2020) Posted on 02/07/2019 04:24pm

A bill for an act
relating to health care; requiring health plan companies to develop and implement
a shared savings incentive program; proposing coding for new law in Minnesota
Statutes, chapter 62Q.

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

Section 1.

new text begin [62Q.05] SHARED SAVINGS INCENTIVE PROGRAM.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For purposes of this section, the following terms have
the meanings given.
new text end

new text begin (b) "Allowed amount" means the contractually agreed upon amount paid for a health
care service to a health care provider participating in the health plan company's provider
network. The contractually agreed upon amount includes the amount paid to the provider
by the health plan company and any cost-sharing required to be paid to the provider by the
enrollee, including co-payments, deductibles, or coinsurance.
new text end

new text begin (c) "Average" means median or mean.
new text end

new text begin (d) "Commissioner" means the commissioner of health.
new text end

new text begin (e) "Comparable health care service" means a covered nonemergency health care service
for which a health plan company offers a shared savings incentive payment pursuant to this
section. Comparable health care services include, at a minimum, health care services within
the following categories:
new text end

new text begin (1) physical and occupational therapy services;
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new text begin (2) obstetrical and gynecological services;
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new text begin (3) radiology and imaging services;
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new text begin (4) laboratory services;
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new text begin (5) infusion therapy services;
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new text begin (6) inpatient and outpatient surgical procedures; and
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new text begin (7) outpatient nonsurgical diagnostic tests and procedures.
new text end

new text begin The commissioner may limit what is considered a comparable health care service if a health
plan company can demonstrate that the allowed amount variation for the service among
in-network providers is less than $50.
new text end

new text begin (f) "Program" means the shared savings incentive program established by a health plan
company pursuant to this section.
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new text begin Subd. 2. new text end

new text begin General. new text end

new text begin (a) Beginning January 1, 2020, each health plan company offering a
health plan in this state must offer a shared savings incentive program to its enrollees that
meets the requirements of this section.
new text end

new text begin (b) Prior to offering the program, a health plan company must file a description of the
program established by the health plan company pursuant to this section with the
commissioner in a manner prescribed by the commissioner. The commissioner shall review
the filing to ensure that the proposed program complies with the requirements of this section.
new text end

new text begin Subd. 3. new text end

new text begin Cost information website. new text end

new text begin (a) The commissioner shall develop a web-based
interactive system for consumers to use to compare provider average charges for health care
services by procedure or procedure code (CPT code). At a minimum, the health care services
compared must include the comparable health care services defined under subdivision 1.
new text end

new text begin (b) Charges identified on the website do not constitute a legally binding estimate of the
allowable charge for or cost to the consumer for the specific health care service, and the
actual cost of the service may vary based on individual circumstances.
new text end

new text begin (c) The commissioner must contract with a private entity to satisfy the requirements of
this subdivision.
new text end

new text begin Subd. 4. new text end

new text begin Shared savings incentive account. new text end

new text begin A health plan company must establish a
shared savings incentive account for each enrollee. The health plan company shall deposit
into the account any incentive payments earned by the enrollee through the program. Funds
in the account may be withdrawn by the enrollee to pay any applicable co-payments,
coinsurance, or deductibles. If an enrollee's out-of-pocket maximum has been met for the
year or there are unused funds in this account at the end of the contract year, the enrollee
may withdraw the funds in the account to pay for premiums for the current contract year or
the following contract year.
new text end

new text begin Subd. 5. new text end

new text begin Program requirements. new text end

new text begin (a) A health plan company must develop and implement
a shared savings incentive program that provides incentives for an enrollee who receives a
comparable health care service that is covered under the enrollee's health plan from a health
care provider that charges less than the average allowed amount paid by that health plan
company for that health care service. A health plan company may enter into a contract with
a third-party entity to develop and implement the health plan company's shared savings
incentive program.
new text end

new text begin (b) The program must provide an enrollee with at least 50 percent of the saved costs for
each comparable health care service resulting in comparison shopping by the enrollee. A
health plan company is not required to provide a payment to an enrollee if the health plan
company's saved cost for a comparable health care service is $25 or less. Compliance with
this paragraph may be demonstrated in the aggregate of health plans offered by the health
plan company within the state based on a reasonably anticipated mix of claims.
new text end

new text begin (c) The incentive offered may be calculated as a percentage of the difference in the
average allowed amount and the price paid, or by using another reasonable methodology
approved by the commissioner. The health plan company shall deposit any incentive earned
by the enrollee into the enrollee's shared savings incentive account established under
subdivision 4.
new text end

new text begin (d) A health plan company must determine a process for documenting that the provider
chosen by an enrollee charges less for a comparable health care service than the average
allowed amount paid by that health plan company. The health plan company may require
the enrollee to demonstrate through reasonable documentation, such as a quote from the
health care provider, that the enrollee comparison shopped prior to receiving care from a
health care provider that charges less for the comparable health care service than the average
allowed amount paid by the health plan company.
new text end

new text begin Subd. 6. new text end

new text begin Allowed amount; disclosure. new text end

new text begin (a) A health plan company may base the average
allowed amount paid to an in-network health care provider for a comparable health care
service on what is paid to an in-network health care provider applicable to the enrollee's
specific health plan, or across all of its health plans offered in the state. A health plan
company may determine an alternative methodology for calculating the average allowed
amount if approved by the commissioner.
new text end

new text begin (b) A health plan company must establish an interactive mechanism that enables an
enrollee to request and obtain information from the health plan company on the payments
made for comparable health care services, as well as quality data. The interactive mechanism
must allow an enrollee to seek information about the cost of a specific comparable health
care service in order to compare the average allowed amount paid to in-network health care
providers based on the enrollee's health plan. The mechanism must also provide a good
faith estimate of the anticipated charges and out-of-pocket costs an enrollee would be
responsible to pay for a comparable health care service if provided by an in-network health
care provider, including any co-payment, deductible, or coinsurance or other out-of-pocket
amount, based on the enrollee's health plan and information available to the health plan
company at the time the request is made. A health plan company may contract with a
third-party vendor to satisfy this requirement.
new text end

new text begin (c) A health plan company must inform an enrollee of the enrollee's ability to request
the average allowed amount paid for a comparable health care service on the health plan
company's website and in the health plan benefits materials.
new text end

new text begin Subd. 7. new text end

new text begin Out-of-network provider. new text end

new text begin (a) If an enrollee elects to receive a comparable
health care service from an out-of-network provider at a price that is less than the average
allowed amount paid by the enrollee's health plan company to an in-network provider, then
the health plan company must allow the enrollee to obtain the health care service from the
out-of-network provider, at the out-of-network provider's price. Upon request of the enrollee,
the health plan company must apply the payments made by the enrollee for that health care
service toward the enrollee's deductible and out-of-pocket maximum as specified by the
enrollee's health plan as if the health care service had been provided by an in-network
provider. If the enrollee's deductible has been met, the enrollee may submit the claim to the
health plan company, and the health plan company must pay the claim in the same manner
as claims submitted by an in-network provider.
new text end

new text begin (b) A health plan company must provide a downloadable or interactive online form to
the enrollee for submitting proof of payment to an out-of-network provider for purposes of
administering this subdivision, if the enrollee directly pays the out-of-network provider.
new text end

new text begin Subd. 8. new text end

new text begin Notice to enrollees by health plan company. new text end

new text begin (a) A health plan company must
make the program available as a component to any health plan offered by the health plan
company to a Minnesota resident. Upon enrollment and annually upon renewal, a health
plan company must provide notice to each enrollee of the availability of the program, a
description of the incentives available to an enrollee, how an enrollee can earn those
incentives, and the comparable health care services that may qualify for a shared savings
incentive payment. The notice must inform enrollees of their right to obtain services from
a different health care provider regardless of any referral or recommendation made by a
specific health care provider or entity, and that seeing a different health care provider, either
the health care provider to which the referral was made or a different health care provider,
may result in an incentive to the enrollee if the enrollee follows the steps set by the enrollee's
health plan company.
new text end

new text begin (b) The health plan company must also provide this information on the health plan
company's website.
new text end

new text begin Subd. 9. new text end

new text begin Notice to enrollee by provider. new text end

new text begin Health care providers must post in a visible
area notification of a patient's ability, for those with individual or small group coverage, to
obtain a description of the service or the applicable standard medical codes or current
procedural terminology codes sufficient to allow a health plan company to assist the patient
in comparing out-of-pocket and contracted amounts paid for their care to different health
care providers for similar services. The notification must notify the patient that the patient's
health plan company is required to provide enrollees with an estimate of the out-of-pocket
costs and the average allowed amount paid for the patient's care. A health care provider
may provide additional information to a patient that informs the patient of specific price
transparency mechanisms or websites that may be available to the patient.
new text end

new text begin Subd. 10. new text end

new text begin No administrative expense. new text end

new text begin A shared savings incentive payment made by a
health plan company according to section is not an administrative expense of the health
plan company for purposes of rate development or rate filing, and may be considered a
medical expense for purposes of medical loss ratio requirements.
new text end

new text begin Subd. 11. new text end

new text begin Exclusions. new text end

new text begin This section does not apply to health plans offered to enrollees
who are enrolled in a public health care program under chapter 256B or 256L.
new text end

new text begin Subd. 12. new text end

new text begin Report. new text end

new text begin (a) By March 1 of each year beginning March 1, 2021, a health plan
company must file with the commissioner for the previous calendar year:
new text end

new text begin (1) the total number of shared savings incentive payments made pursuant to this section;
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new text begin (2) the use of comparable health care services by category of service for which shared
savings incentive payments were made;
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new text begin (3) the average amount of shared savings incentive payments made by category of
service;
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new text begin (4) the total savings achieved below the average prices by category of service; and
new text end

new text begin (5) the total number and percentage of the health plan company's enrollees who
participated in the program.
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new text begin (b) By April 15 of each year beginning April 15, 2021, the commissioner of health shall
submit an aggregate report containing the information submitted under paragraph (a) by
the health plan companies to the chairs and ranking minority members of the committees
in the senate and house of representatives with jurisdiction over health insurance.
new text end

new text begin Subd. 13. new text end

new text begin Citation. new text end

new text begin This section may be cited as the "Patient Right To Shop Act."
new text end