2006 Minnesota Statutes

62Q.74 NETWORK SHADOW CONTRACTING.
    Subdivision 1. Definitions. (a) For purposes of this section, "category of coverage" means
one of the following types of health-related coverage:
(1) health;
(2) no-fault automobile medical benefits; or
(3) workers' compensation medical benefits.
(b) "Health care provider" or "provider" means a physician, chiropractor, dentist, podiatrist,
hospital, ambulatory surgical center, freestanding emergency room, or other provider, as defined
in section 62J.03.
    Subd. 2. Provider consent required. (a) No health plan company shall require a health care
provider to participate in a network under a category of coverage that differs from the category or
categories of coverage to which the existing contract between the health plan company and the
provider applies, without the affirmative consent of the provider obtained under subdivision 3.
(b) No health plan company shall require, as a condition of participation in any health
plan, product, or other arrangement, the provider to participate in a new or different health plan,
product, or other arrangement within a category of coverage that results in a different underlying
financial reimbursement methodology without the affirmative consent of the provider obtained
under subdivision 3. This paragraph does not apply to participation in health plan products or
other arrangements that provide health care services to government programs, including state
public programs, Medicare, and Medicare-related coverage.
(c) Compliance with this section may not be waived in a contract or otherwise.
    Subd. 3. Consent procedure. (a) The health plan company, if it wishes to apply an
existing contract with a provider to a different category of coverage or health plan, product, or
other arrangement within a category of coverage that results in a different underlying financial
reimbursement methodology, shall first notify the provider in writing. The written notice must
include at least the following:
(1) the health plan company's name, address, and telephone number, and the name of the
specific network, if it differs from that of the health plan company;
(2) a description of the proposed new category of coverage or health plan, product, or other
arrangement within a category of coverage;
(3) the names of all payers expected by the health plan company to use the network for the
new category of coverage or health plan, product, or other arrangement within a category of
coverage;
(4) the approximate number of current enrollees of the health plan company in that category
of coverage or health plan, product, or other arrangement within a category of coverage within the
provider's geographical area;
(5) a disclosure of all contract terms of the proposed new category of coverage or health plan,
product, or other arrangement within a category of coverage, including the discount or reduced
fees, care guidelines, utilization review criteria, prior notification process, prior authorization
process, and dispute resolution process;
(6) a form for the provider's convenience in accepting or declining participation in the
proposed new category of coverage or health plan, product, or other arrangement within a
category of coverage, provided that the provider need not use that form in responding; and
(7) a statement informing the provider of the provisions of paragraph (b).
(b) Unless the provider has affirmatively agreed to participate within 60 days after the
postmark date of the notice, the provider is deemed to have not accepted the proposed new
category of coverage or health plan, product, or other arrangement within a category of coverage
that results in a different underlying financial reimbursement methodology.
    Subd. 4. Contract termination restricted. A health plan company must not terminate an
existing contract with a provider, or fail to honor the contract in good faith, based solely on the
provider's decision not to accept a proposed new category of coverage or health plan, product, or
other arrangement within a category of coverage that results in a different underlying financial
reimbursement methodology. The most recent agreed-upon contractual obligations remain in
force until the existing contract's renewal or termination date.
    Subd. 5. Remedy. If a health plan company violates this section by reimbursing a provider
as if the provider had agreed under this section to participate in the network under a category
of coverage or health plan, product, or other arrangement within a category of coverage that
results in a different underlying financial reimbursement methodology to which the provider
has not agreed, the provider has a cause of action against the health plan company to recover
two times the difference between the reasonable charges for claims affected by the violation
and the amounts actually paid to the provider. The provider is also entitled to recover costs,
disbursements, and reasonable attorney fees.
    Subd. 6. Benefit design changes. For purposes of this section, "different underlying financial
reimbursement methodology" does not include health plan benefit design changes, including,
but not limited to, changes in co-payment or deductible amounts or other changes in member
cost-sharing requirements.
History: 1999 c 94 s 1; 2000 c 322 s 1; 2001 c 170 s 4,5; 2004 c 246 s 9