Health plans to credit enrollees for services provided by out-of-network provider at a lower cost than the plan's in-network providers

A bill for an act

relating to insurance; requiring health plans to credit enrollees for services provided

by an out-of-network provider at a lower cost than the plan's in-network providers;

authorizing commissioner of commerce enforcement; amending Minnesota Statutes

2024, sections 62J.81, subdivision 1a; 290.0132, by adding a subdivision; proposing

coding for new law in Minnesota Statutes, chapter 62J.

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

Section 1.

Minnesota Statutes 2024, section 62J.81, subdivision 1a, is amended to read:

Subd. 1a.

Required disclosure by health plan company.

(a) A health plan company,

as defined in section
62J.03
, subdivision 10, shall, at the request of an enrollee intending

to receive specific health care services or the enrollee's designee, provide that enrollee with

a good faith estimate of
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:
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(1)
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the allowable amount the health plan company has contracted for with a specified

provider within the network as total payment for a health care service specified by the

enrollee and the portion of the allowable amount due from the enrollee and the enrollee's

out-of-pocket costs
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.
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; or
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(2) the lowest allowable amount due from the enrollee as total payment for the health

care service for any provider, comparable to the out-of-network provider specified by the

enrollee for an out-of-network credit under section 62J.829 in (i) qualification to perform

the health care service and (ii) geographic accessibility, within the network.

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An estimate provided to an enrollee under this paragraph is not a legally binding estimate

of the allowable amount or enrollee's out-of-pocket cost.

(b) The information required under this subdivision must be provided by the health plan

company to an enrollee within ten business days from the day a complete request was

received by the health plan company. For purposes of this section, "complete request"

includes all the patient and service information the health plan company requires to provide

a good faith estimate, including a completed good faith estimate form if required by the

health plan company.

Sec. 2.

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[62J.829] COST-SHARING CREDIT FOR OUT-OF-NETWORK SERVICES.

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Subdivision 1.

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Definitions.

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(a) For purposes of this section, the following terms have

the meanings given.

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(b) "Estimated in-network cost difference" means the good faith estimate an enrollee

receives for a service from the health plan pursuant to section 62J.81, subdivision 1a,

paragraph (a), clause (2), minus the good faith estimate an enrollee receives for the service

from an out-of-network provider pursuant to section 62J.81, subdivision 1.

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(c) "Out-of-network credit" means the credit required under subdivision 2.

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Subd. 2.

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Required credit.

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(a) Subject to paragraph (d), all health plans must issue a

credit to an enrollee if the enrollee:

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(1) received a health care service from a provider outside of the health plan's network;

and

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(2) identified a positive estimated in-network cost difference for the health care service

from the out-of-network provider before receiving the service.

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(b) Subject to paragraph (d), the credit required under paragraph (a) must be equal to

fifty percent of the estimated in-network cost difference. The health plan may require the

enrollee to provide reasonable documentation of the good faith estimates received from the

provider under section 62J.81, subdivision 1, before issuing the out-of-network credit. The

health plan is prohibited from conditioning the out-of-network credit on the health plan's

receipt of documentation of the good faith estimates before the enrollee receives the health

care service.

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(c) Unless a request otherwise is made to the health plan by the enrollee or the enrollee's

designee, a health plan must apply an enrollee's out-of-network credit immediately, and

without any required action by the enrollee, as an offset against the enrollee's next due

payment obligation to the health plan until the enrollee has no available credit.

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(d) The maximum aggregate amount of out-of-network credits an enrollee may have at

any time for a single health plan is $........ A health plan is not required to issue an

out-of-network credit if:

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(1) the health care service is provided outside the United States; or

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(2) the enrollee is delinquent on payment of premiums.

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Subd. 3.

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Prohibition on limiting plan designs.

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A health plan must not impose any

cost-sharing requirement, utilization review limitation, or premium increase that limits an

enrollee's ability to receive, benefit from, or use an out-of-network credit. A premium

increase or cost-sharing increase directly or indirectly related to the amount of an enrollee's

out-of-network credit balance is considered a limit on an enrollee's ability to receive, benefit

from, or use an out-of-network credit. The prohibition under this subdivision applies to an

enrollee's existing plan, plan renewals, and health plan changes with the same health plan

company or the company's successor.

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Subd. 4.

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Notice of credit balance.

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For each enrollee with a nonzero credit balance, a

health plan must provide a statement of the credit balance at least once every ... months.

The statement must clearly identify the enrollee's accruals and uses of out-of-network credits

within the past year and the currently available out-of-network credit balance.

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Subd. 5.

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Credit payment upon plan termination.

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(a) Subject to paragraph (b), a health

plan must pay an amount equal to the available out-of-network credit balance to an enrollee

upon the cancellation, termination, expiration, or lapse of the health plan by the enrollee,

health plan, or law.

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(b) A health plan is not required to make the payment under paragraph (a) if the health

plan is canceled, terminated, expired, or lapsed due to the enrollee's nonpayment of premiums,

material misrepresentation, or fraud.

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Subd. 6.

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Application.

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If the application of this section before an enrollee has met their

health plan's deductible would result in: (1) health savings account ineligibility under United

States Code, title 26, section 223; or (2) catastrophic health plan ineligibility under United

States Code, title 42, section 18022(e), this section applies only after the enrollee has met

the enrollee's health plan's deductible.

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Subd. 7.

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Enforcement.

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The commissioner of commerce may investigate and enforce

this section using any of the authority granted to the commissioner under section 45.027.

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Sec. 3.

Minnesota Statutes 2024, section 290.0132, is amended by adding a subdivision

to read:

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Subd. 40.

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Out-of-network credit balance.

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The amount of the out-of-network credit

balance paid to an enrollee under section 62J.829, subdivision 5, is a subtraction.

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EFFECTIVE DATE.

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This section is effective for taxable years beginning after December

31, 2025.

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