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SF 3485

as introduced - 91st Legislature (2019 - 2020) Posted on 02/25/2020 08:20am

KEY: stricken = removed, old language.
underscored = added, new language.
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A bill for an act
relating to health care; requiring disclosure of certain health care provider
reimbursement arrangements to enrollees and health care providers; modifying
the duties of the ombudsperson for public managed health care programs; providing
health carrier liability when a health care provider is limited in providing services
by the health carrier; amending Minnesota Statutes 2018, sections 62J.72,
subdivision 1; 62Q.735, subdivision 1; 256B.69, subdivision 20; proposing coding
for new law in Minnesota Statutes, chapter 604.

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

Section 1.

Minnesota Statutes 2018, section 62J.72, subdivision 1, is amended to read:


Subdivision 1.

Written disclosure.

(a) A health plan company, as defined under section
62J.70, subdivision 3, a health care network cooperative as defined under section 62R.04,
subdivision 3
, and a health care provider as defined under section 62J.70, subdivision 2,
shall, during open enrollment, upon enrollment, and annually thereafter, provide enrollees
with a description of the deleted text begingeneral nature of thedeleted text end reimbursement methodologies used by the
health plan company, health insurer, or health coverage plan to pay providers. The description
must explain clearly any aspect of the reimbursement methodology that creates a financial
incentive for the health care provider to limit or restrict the health care provided to enrolleesdeleted text begin.deleted text endnew text begin,
including any aspect of a reimbursement methodology in which:
new text end

new text begin (1) payments to health care providers are based on the volume of care provided or the
number of referrals to or utilization of specialists;
new text end

new text begin (2) providers provide services to a specified patient population for an agreed-upon total
cost of care or are reimbursed under a risk-sharing or gain-sharing payment arrangement;
or
new text end

new text begin (3) provider reimbursement is based on provider tiering, with providers assigned to tiers
based on the cost of care provided, the volume of care provided, or the number of referrals
to or utilization of specialists.
new text end

new text begin The description must also clearly explain how the reimbursement methodology operates to
limit or restrict, or how it may have the effect of limiting or restricting, the health care
provided to enrollees, and specific limitations or restrictions of health care that enrollees
may experience.
new text endAn entity required to disclose shall also disclose if no reimbursement
methodology is used that creates a financial incentive for the health care provider to limit
or restrict the health care provided to enrollees. This description may be incorporated into
the member handbook, subscriber contract, certificate of coverage, or other written enrollee
communication. The deleted text begingeneraldeleted text end reimbursement methodology shall be made available to
employers at the time of open enrollment.

(b) Health plan companies, health care network cooperatives, and providers must, upon
request, provide an enrollee with specific information regarding the reimbursement
methodology, including, but not limited to, the following information:

(1) a concise written description of the provider payment plan, including any incentive
plan applicable to the enrollee;

(2) a written description of any incentive to the provider relating to the provision of
health care services to enrollees, including any compensation arrangement that is dependent
on the amount of health coverage or health care services provided to the enrollee, or the
number of referrals to or utilization of specialists; and

(3) a written description of any incentive plan that involves the transfer of financial risk
to the health care provider.

(c) The disclosure statementnew text begin under paragraph (a)new text end describing the deleted text begingeneral nature of thedeleted text end
reimbursement methodologies must comply with the Readability of Insurance Policies Act
in chapter 72C and must be filed with and approved by the commissioner prior to its use.

(d) A disclosure statement that has been filed with the commissioner for approval under
paragraph (c) is deemed approved 30 days after the date of filing, unless approved or
disapproved by the commissioner on or before the end of that 30-day period.

(e) The disclosure statementnew text begin under paragraph (a)new text end describing the deleted text begingeneral nature of thedeleted text end
reimbursement methodologies must be provided upon request in English, Spanish,
Vietnamese, and Hmong. In addition, reasonable efforts must be made to provide information
contained in the disclosure statement to other non-English-speaking enrollees.

(f) deleted text beginHealth plan companies and providers may enter into agreements to determine how
to respond to enrollee requests received by either the provider or the health plan company.
This subdivision does not require disclosure of specific amounts paid to a provider, provider
deleted text enddeleted text begin fee schedules, provider salaries, or other proprietary information of a specific health plan
company or health insurer or health coverage plan or provider
deleted text endnew text begin The disclosures required by
this subdivision are deemed to not constitute disclosures of proprietary or trade secret
information
new text end.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021.
new text end

Sec. 2.

Minnesota Statutes 2018, section 62Q.735, subdivision 1, is amended to read:


Subdivision 1.

Contract disclosure.

(a) Before requiring a health care provider to sign
a contract, a health plan company shall give to the provider a complete copy of the proposed
contract, including:

(1) all attachments and exhibits;

(2) operating manuals;

(3) a general description of the health plan company's health service coding guidelines
and requirement for procedures and diagnoses with modifiers, and multiple procedures; and

(4) all guidelines and treatment parameters incorporated or referenced in the contract.

(b) The health plan company shall make available to the providernew text begin:
new text end

new text begin (1)new text end the fee schedule or a method or process that allows the provider to determine the fee
schedule for each health care service to be provided under the contractdeleted text begin.deleted text endnew text begin; and
new text end

new text begin (2) a description of any conditions in the contract that are related to provider
reimbursement and that may have the effect of limiting or restricting the health care services
the provider provides to enrollees.
new text end

(c) Notwithstanding paragraph (b), a health plan company that is a dental plan
organization, as defined in section 62Q.76, shall disclose information related to the individual
contracted provider's expected reimbursement from the dental plan organization. Nothing
in this section requires a dental plan organization to disclose the plan's aggregate maximum
allowable fee table used to determine other providers' fees. The contracted provider must
not release this information in any way that would violate any state or federal antitrust law.

new text begin (d) The disclosures required by this subdivision are deemed to not constitute disclosures
of proprietary or trade secret information.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021.
new text end

Sec. 3.

Minnesota Statutes 2018, section 256B.69, subdivision 20, is amended to read:


Subd. 20.

Ombudsperson.

The commissioner shall designate an ombudsperson to
advocate for persons required to enroll in prepaid health plans under this section. The
ombudsperson shall advocate for recipients enrolled in prepaid health plans through complaint
and appeal procedures and ensure that necessary medical services are provided either by
the prepaid health plan directly or by referral to appropriate social services. new text beginThe
ombudsperson shall also provide assistance to a recipient who requests assistance with
understanding the description, provided under section 62J.72, subdivision 1, of the
methodology used by the recipient's prepaid health plan to reimburse health care providers
and how that reimbursement methodology may have the effect of limiting or restricting the
health care provided to the recipient. Disclosure under this subdivision of information on
the reimbursement methodology is deemed to not constitute the disclosure of proprietary
or trade secret information.
new text endAt the time of enrollment in a prepaid health plan, the local
agency shall inform recipients about the ombudsperson programnew text begin; their right to assistance
from the ombudsman, through a consultation by telephone or in another manner, with
understanding their prepaid health plan's reimbursement methodology;
new text end and their right to a
resolution of a complaint by the prepaid health plan if they experience a problem with the
plan or its providers.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021.
new text end

Sec. 4.

new text begin [604.112] HEALTH CARRIER LIABILITY.
new text end

new text begin Subdivision 1. new text end

new text begin Definition. new text end

new text begin For purposes of this section, "health carrier" has the meaning
given in section 62A.011, subdivision 2.
new text end

new text begin Subd. 2. new text end

new text begin Liability. new text end

new text begin If a health carrier agrees to compensate a health care provider for
the provisions of services to a patient and the amount of the compensation is conditioned
by a limit on the amount of services to be provided by the provider, then the health carrier
is liable for an injury to a patient caused in whole or in part by a delay or denial of care if
the delay or denial of care was a consequence of the limit.
new text end

new text begin Subd. 3. new text end

new text begin Information on reimbursement methodology. new text end

new text begin Disclosure in an action brought
under this section of information on the reimbursement methodology used by a health carrier
to compensate a health care provider is deemed to not constitute the disclosure of proprietary
or trade secret information.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective for causes of action accruing on or after
August 1, 2020.
new text end