HF 2613

as introduced - 91st Legislature (2019 - 2020) Posted on 03/27/2019 01:32pm

A bill for an act
relating to health insurance; establishing a pilot program in southeastern Minnesota
that requires health plan companies to develop and implement a shared savings
incentive program.

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

Section 1. new text begin SOUTHEASTERN MINNESOTA; SHARED SAVINGS INCENTIVE
PILOT 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 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 the enrollee must pay to the provider, 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
a health plan company offers a shared savings incentive payment for under 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 the services that are considered a comparable health care
service if a health plan company demonstrates that the allowed amount variation for the
service among in-network providers is less than $50.
new text end

new text begin (f) "Enrollee" means a natural person who resides or works in southeastern Minnesota
and is covered by a health plan.
new text end

new text begin (g) "Health plan" has the meaning given in Minnesota Statutes, section 62Q.01,
subdivision 3.
new text end

new text begin (h) "Health plan company" has the meaning given in Minnesota Statutes, section 62Q.01,
subdivision 4.
new text end

new text begin (i) "Program" means the shared savings incentive program established by a health plan
company under this section.
new text end

new text begin (j) "Southeastern Minnesota" means the portion of Minnesota that is part of geographic
rating area 1, as determined under Minnesota Statutes, section 62A.65, subdivision 3,
paragraph (b).
new text end

new text begin Subd. 2. new text end

new text begin General. new text end

new text begin (a) Beginning January 1, 2020, and until January 1, 2022, each health
plan company offering a health plan in southeastern Minnesota must offer to its enrollees
a shared savings incentive program 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 under this section with the commissioner
in a manner prescribed by the commissioner. The commissioner must review the filing to
ensure that the proposed program complies with 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 must develop a web-based
interactive system for consumers in southeastern Minnesota to use to compare provider
average charges for health care services on a procedure or procedure code (CPT code) basis.
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 or cost to the consumer for the specific health care service. 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 must 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 the account at the end of the contract year, the enrollee
may withdraw the funds in the account to pay 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 the 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 in southeastern Minnesota, based on a reasonably anticipated mix of claims.
new text end

new text begin (c) The incentive offered may be calculated (1) as a percentage of the difference in the
average allowed amount and the price paid, or (2) by using another reasonable methodology
approved by the commissioner. The health plan company must 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 to document 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, including 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 (1) to an in-network health care provider applicable to the enrollee's
specific health plan, or (2) across all of its health plans offered in the state. A health plan
company may determine an alternative method to calculate 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 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,
including any co-payment, deductible, coinsurance, or other out-of-pocket amount, for a
comparable health care service if the service is provided by an in-network health care
provider 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, 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) For purposes of administering this subdivision, a health plan company must provide
a downloadable or interactive online form for an enrollee to submit proof of a direct payment
to an 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 of any health plan offered by the health plan
company to those residing or working in southeastern Minnesota. Upon enrollment and
annually upon renewal, a health plan company must provide notice to each enrollee of the
program's availability, a description of the incentives available to an enrollee, how an enrollee
may earn those incentives, and the comparable health care services that may qualify for a
shared savings incentive payment. The notice must inform an enrollee of the enrollee's 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 receiving services
from 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 established by the enrollee's health plan company.
new text end

new text begin (b) The health plan company must provide the information required under paragraph
(a) 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 located in southeastern
Minnesota must post notification in a visible area that informs a patient with individual or
small group coverage of the patient's ability 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 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 under this 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 Minnesota Statutes, 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, 2021, and March 1, 2022, 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 under 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 residing or
working in southeastern Minnesota who participated in the program.
new text end

new text begin (b) By April 15, 2021, and April 15, 2022, the commissioner must submit an aggregate
report containing the information submitted by the health plan companies under paragraph
(a) 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 EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment and
applies to health plans offered, sold, or issued in southeastern Minnesota on or after January
1, 2020.
new text end