SF 4222

as introduced - 93rd Legislature (2023 - 2024) Posted on 02/27/2024 09:06am

A bill for an act
relating to insurance; allowing health carriers to offer reference-based pricing
health plans; proposing coding for new law in Minnesota Statutes, chapter 62K.

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

Section 1.

new text begin [62K.16] REFERENCE-BASED PRICING HEALTH PLAN.
new text end

new text begin Subdivision 1. new text end

new text begin General. new text end

new text begin Notwithstanding any law to the contrary and upon any necessary
federal approval, a health carrier may offer in the individual, small, and large group market
a reference-based pricing health plan that meets the requirements of this section.
new text end

new text begin Subd. 2. new text end

new text begin Provider participation. new text end

new text begin (a) An enrollee of a reference-based pricing health
plan may access any health care provider who has agreed to: (1) a reimbursement rate up
to but not greater than the reimbursement rate specified in the enrollee's reference-based
pricing plan as defined under subdivision 5; and (2) any other terms and conditions offered
by the health carrier. Any terms and conditions offered by the health carrier must be the
same for all health care providers who agree to participate in the health plan.
new text end

new text begin (b) A health carrier may require a participating provider to meet reasonable data,
utilization review, and quality assurance requirements.
new text end

new text begin (c) A provider who agrees to participate must provide services to all enrollees of the
health plan if the provider's reimbursement rates are equal to or less than those services
specified in the enrollee's health plan.
new text end

new text begin Subd. 3. new text end

new text begin Reimbursement rates. new text end

new text begin (a) The reimbursement rates offered to providers that
agree to participate in a reference-based pricing health plan must be based on a percentage
relative to the rates defined by the most recent medical assistance fee-for-service
reimbursement fee schedules promulgated by the Department of Human Services.
new text end

new text begin (b) For services that do not have a corresponding medical assistance fee-for-service
reimbursement value, the health carrier must negotiate the rates based on other fee schedules
used within the health care market.
new text end

new text begin (c) If a reference-based pricing health plan's reimbursement rate is at least 190 percent
above the medical assistance fee-for-service rate and the health plan is offered in all counties
throughout Minnesota, the health plan is exempt from the geographic and network adequacy
requirements under section 62K.10.
new text end

new text begin (d) A provider who agrees to participate in the health plan agrees to accept the
reimbursement rate as payment in full under the terms of the health plan in accordance with
section 62K.11.
new text end

new text begin Subd. 4. new text end

new text begin Conditions. new text end

new text begin (a) Nothing in this section requires a provider to participate in a
reference-based pricing health plan. A health carrier is prohibited from requiring, as a
condition of participation in any other health plan, product, or other arrangement offered
by the health carrier, that the provider participate in a reference-based pricing health plan.
new text end

new text begin (b) Nothing in this section requires a health carrier to provide coverage for a service or
treatment that is not covered under the enrollee's health plan.
new text end

new text begin (c) A reference-based pricing health plan may impose cost-sharing requirements,
including co-payments, deductibles, and coinsurance and reasonable referral and prior
authorization requirements.
new text end

new text begin Subd. 5. new text end

new text begin Definitions. new text end

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

new text begin (b) "Provider" has the meaning given in section 62J.03, subdivision 8.
new text end

new text begin (c) "Reference-based pricing health plan" means a health plan in which the employer
pays a set price for each service instead of negotiating prices with providers.
new text end