SF3993
Health plans to credit enrollees for services provided by out-of-network provider at a lower cost than the plan's in-network providers
Legislative Session 94 (2025-2026)
Related bill: HF4152
AI Generated Summary
Purpose
- To require health plan companies to credit enrollees who receive health care services from out-of-network providers when the out-of-network cost would be lower than the plan’s in-network cost.
- To provide a process for enrollees to obtain a good faith cost estimate and to receive an out-of-network credit that lowers the enrollee’s final payment.
Main provisions
Good faith cost estimates (Section 62J.81, subdivision 1a)
- Health plan companies must, within ten business days after a complete request, provide an enrollee (or their designee) with:
- A good faith estimate of the total payment the plan has contracted for with a specified network provider for a health care service, plus the enrollee’s share (out-of-pocket costs), or
- The lowest total payment the enrollee would owe for the service from any provider comparable to the out-of-network provider, considering geographic accessibility.
- The estimate is not a legally binding quote.
- A complete request includes all information the plan needs to issue the estimate (forms may be required).
Definitions used for credits (Section 62J.829)
- Estimated in-network cost difference: good faith in-network estimate minus the out-of-network estimate.
- Out-of-network credit: a credit equal to 50% of the estimated in-network cost difference.
- The plan may ask for documentation of the good faith estimates but cannot require it before the enrollee receives the service.
When credits must be issued (Subdivision 2)
- Plans must issue an out-of-network credit if the enrollee received care from an out-of-network provider and identified a positive estimated in-network cost difference before the service.
- The credit equals 50% of the estimated difference.
- The credit may be applied as an offset to the enrollee’s next due payment and should be applied immediately unless the enrollee requests otherwise.
- The enrollee’s obligation to use the credit is subject to a limit on total credits per plan per enrollee (see below for the cap note).
Limits and restrictions (Subdivision 2)
- Credits are not available if:
- The service is provided outside the United States, or
- The enrollee is delinquent on premium payments.
- There is a maximum total amount of out-of-network credits an enrollee may have with a single health plan (the exact cap is not specified in the provided text).
No punitive design changes (Subdivision 3)
- Health plans may not impose cost-sharing, utilization review limits, or premium increases that would reduce an enrollee’s ability to receive or use an out-of-network credit.
- A premium or cost-sharing change tied to the credit is considered a limit on the enrollee’s ability to receive the benefit.
Notices of credit balance (Subdivision 4)
- Plans must provide an enrollee with a statement of their credit balance at least periodically (frequency is described in the bill but not specified in the excerpt).
Credit balance treatment at plan termination (Subdivision 5)
- If a plan ends for any reason, the plan must pay the available out-of-network credit balance to the enrollee, except in cases of nonpayment of premiums, material misrepresentation, or fraud.
Application timing (Subdivision 6)
- If applying the credit before an enrollee meets their deductible would affect tax-advantaged accounts (like an HSA) or catastrophic coverage eligibility, the credit applies only after the enrollee meets the deductible.
Enforcement (Subdivision 7)
- The Minnesota Commissioner of Commerce can investigate and enforce these provisions using its existing authority.
Related amendment to another statute (Section 3)
- Adds a reference to “out-of-network credit balance” in Minnesota Statutes, indicating how the credit balance is treated for purposes of subtraction in a related provision.
Significant changes to existing law
- Creates a formal framework for out-of-network credits:
- Introduces the concept of an out-of-network credit equal to 50% of the estimated in-network cost difference.
- Establishes a process for obtaining and applying good faith estimates.
- Requires disclosures and ongoing credit balance reporting.
- Adds enforcement by the Commissioner of Commerce.
- Amends multiple statutes to incorporate the credit system:
- Adds details to section 62J.81 (disclosures to enrollees) and 62J.829 (credit mechanics) and references to out-of-network credit balances in related statutory provisions (e.g., 290.0132).
How this could affect enrollees and plans
- Enrollees could receive a 50% credit when using an out-of-network provider if the out-of-network cost difference is positive and before the service is performed.
- Credits can be applied immediately to reduce the enrollee’s next payment, and balances must be tracked and disclosed.
- Plans must provide timely good faith estimates and cannot condition the credit on obtaining additional documentation after services are performed.
- The bill imposes safeguards to prevent plans from using credits to justify higher premiums, more cost-sharing, or other limitations on benefits.
Enforcement and oversight
- The Commissioner of Commerce would have authority to investigate and enforce these provisions.
Relevant terms
- out-of-network credit
- in-network cost difference
- estimated in-network cost difference
- good faith estimate
- health plan company
- enrollee
- out-of-network services
- credit balance
- immediate offset
- complete request
- geographic accessibility
- notice of credit balance
- enforcement
- Commissioner of Commerce
- Section 62J.81
- Section 62J.829
- Minnesota Statutes 2024
- 290.0132 Subd.40
- deductible
- out-of-network provider
- cost sharing
- premium
- utilization review
- misrepresentation
- fraud
Bill text versions
- Introduction PDF PDF file
Actions
| Date | Chamber | Where | Type | Name | Committee Name |
|---|---|---|---|---|---|
| March 02, 2026 | Senate | Action | Introduction and first reading | ||
| March 02, 2026 | Senate | Action | Referred to | Commerce and Consumer Protection |
Citations
[
{
"analysis": {
"added": [
"Mandatory good-faith estimate disclosures to enrollees on request.",
"Two disclosure options: (a) contracted total payment and enrollee costs; (b) lowest in-network amount for a comparable provider for an out-of-network credit."
],
"removed": [],
"summary": "Amends Minnesota Statutes 2024 section 62J.81, Subd. 1a to require health plan companies to provide enrollees with a good-faith estimate of costs upon request, offering two disclosure options: (i) total payment and enrollee out-of-pocket costs for a network provider, or (ii) the lowest in-network amount for a provider comparable to an out-of-network provider for an out-of-network credit under §62J.829; estimates are nonbinding and must be delivered within ten business days.",
"modified": [
"Introduces disclosure requirements and timelines; establishes nonbinding nature of estimates."
]
},
"citation": "62J.81",
"subdivision": "Subd.1a"
},
{
"analysis": {
"added": [
"Definitions for key terms used in the out-of-network credit provisions."
],
"removed": [],
"summary": "Adds Subd. 1 (Definitions) to 62J.829, creating definitions used for the cost-sharing credit program, including terms like 'Estimated in-network cost difference' and 'Out-of-network credit'.",
"modified": []
},
"citation": "62J.829",
"subdivision": "Subd.1"
},
{
"analysis": {
"added": [
"Credit amount equal to 50% of the estimated in-network cost difference.",
"Plan may require documentation of good-faith estimates before issuing the credit.",
"Credit applied automatically as an offset to the next due payment."
],
"removed": [],
"summary": "Sets the amount of the out-of-network credit: equal to 50% of the estimated in-network cost difference; allows plan to require documentation of good-faith estimates; credit can be applied as an offset to the enrollee's next payment.",
"modified": []
},
"citation": "62J.829",
"subdivision": "Subd.2"
},
{
"analysis": {
"added": [
"Prohibition on design features that limit use of out-of-network credits."
],
"removed": [],
"summary": "Prohibits plan designs that limit an enrollee's ability to use an out-of-network credit through cost-sharing, utilization review, or premium increases.",
"modified": []
},
"citation": "62J.829",
"subdivision": "Subd.3"
},
{
"analysis": {
"added": [
"Notice of credit balance required at least every specified number of months."
],
"removed": [],
"summary": "Requires health plans to provide notice of an enrollee's credit balance at defined intervals, detailing accruals and current balance.",
"modified": []
},
"citation": "62J.829",
"subdivision": "Subd.4"
},
{
"analysis": {
"added": [
"Plan must pay the available out-of-network credit balance upon termination/expiration."
],
"removed": [],
"summary": "Governs payment of the credit balance upon plan termination, including conditions for payment.",
"modified": []
},
"citation": "62J.829",
"subdivision": "Subd.5"
},
{
"analysis": {
"added": [
"Conditional applicability to preserve HSA eligibility and catastrophic plan eligibility."
],
"removed": [],
"summary": "Application requirements stating that the section applies only after the enrollee has met the deductible if application would affect HSA eligibility under 26 U.S.C. § 223 or catastrophic plan eligibility under 42 U.S.C. § 18022e.",
"modified": []
},
"citation": "62J.829",
"subdivision": "Subd.6"
},
{
"analysis": {
"added": [
"Enforcement authority aligned with §45.027."
],
"removed": [],
"summary": "Enforcement provision allowing the Commissioner of Commerce to investigate and enforce under §45.027.",
"modified": []
},
"citation": "62J.829",
"subdivision": "Subd.7"
},
{
"analysis": {
"added": [
"New Subd. 40 defining the out-of-network credit balance for tax subtraction purposes."
],
"removed": [],
"summary": "Adds Subd. 40 to Minnesota Statutes 2024 §290.0132 concerning the out-of-network credit balance; states that the amount paid to an enrollee under §62J.829, Subd.5 is treated as a subtraction for tax purposes.",
"modified": []
},
"citation": "290.0132",
"subdivision": "Subd.40"
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "References enforcement authority for the new provisions by linking to the Commissioner of Commerce's authority under §45.027.",
"modified": [
"Enforcement framework referencing §45.027."
]
},
"citation": "45.027",
"subdivision": ""
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "Notes potential impact on Health Savings Account (HSA) eligibility under the Internal Revenue Code.",
"modified": []
},
"citation": "26 U.S.C. § 223",
"subdivision": ""
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "Notes potential impact on catastrophic health plan eligibility under the Public Health Service provisions.",
"modified": []
},
"citation": "42 U.S.C. § 18022e",
"subdivision": ""
}
]Progress through the legislative process
In Committee