HF4225

Purpose

This section creates a limit on what a patient (enrollee) can be charged when a health plan denies coverage for a service that is supposed to be covered. It aims to reduce surprise bills by capping patient charges and clarifying how payments toward a deductible work.

Main provisions

• If a health plan denies coverage for a health care service that is a covered benefit for an enrollee, the provider may not bill the enrollee more than:
  • the negotiated provider payment amount (the rate the provider has agreed to with the health plan) plus 20 percent.
• Any money the enrollee pays toward the denied service under this rule counts toward the enrollee’s deductible.
• The bill does not force a health plan to pay for out-of-network services unless the plan or contract requires it, or if the service isn’t covered under the enrollee’s plan.
• The term “negotiated provider payment” means the payment the provider agrees to accept under the contract between the provider and the health plan for services provided to an enrollee.

Significant changes to existing law

• Establishes a new limit (cap) on patient charges for denied covered services: no more than the negotiated rate plus 20%.
• Clarifies how patient payments toward a deductible are applied when a service is denied.
• Keeps existing rules on out-of-network payment requirements intact (no new obligation to pay out-of-network costs unless the plan/contract already requires it).
• Introduces a formal definition for “negotiated provider payment” within Minnesota health insurance statutes.

How this affects enrollees and providers

• Enrollees are protected from large bills when a service they are entitled to is denied coverage for procedural reasons.
• Providers must adhere to the cap when seeking payment from enrollees for denied covered services.
• The policy ensures that any patient payments under this cap contribute toward deductible progress.

Related terms (for quick reference)

• health plan
• enrollee
• provider
• covered benefit
• denied coverage / denied covered services
• procedural reasons
• negotiated provider payment
• deductible
• out-of-network
• provider contract
• health care services
• Minnesota Statutes Chapter 62Q
• Section 62Q.495

Relevant Terms health plan, enrollee, provider, covered benefit, denied coverage, procedural reasons, negotiated provider payment, deductible, out-of-network, provider contract, health care services, Minnesota Statutes Chapter 62Q, 62Q.495