Purpose

Establishes a limit on what a health plan enrollee may be charged when a covered health service is denied for procedural reasons. The bill creates a new law in Minnesota Statutes chapter 62Q.

Main Provisions

• Cap on charges for denied covered services: If a health plan denies coverage for a health care service that is a covered benefit, the provider may not bill the enrollee more than the negotiated provider payment amount plus 20 percent.
• Crediting toward deductible: Any amount the enrollee pays toward the denied service counts toward the enrollee’s deductible.
• Out-of-network exceptions: The bill does not require a health plan to pay for services provided by an out-of-network provider unless the plan’s terms require it or there is coverage for services not covered under the plan.
• Definition of negotiated payment: For this section, “negotiated provider payment” means the amount the provider agrees to accept under the provider contract with the health plan for services to an enrollee.
• Scope: Applies specifically when coverage is denied for procedural reasons for a service that would otherwise be a covered benefit.

Significant Changes to Existing Law

• Introduces a specific monetary limit on what an enrollee can be charged when a covered service is denied, tying the charge to the negotiated contract rate plus a 20% markup.
• Clarifies how such payments affect deductibles, ensuring payments contribute toward deductible, and limits patient exposure if coverage is denied.
• Reaffirms that plans are not automatically responsible for out-of-network services unless their terms require it or the service is not covered by the plan.
• Establishes a clear legal definition of “negotiated provider payment” tied to the provider’s contract with the health plan.

Practical Impact

• Enrollees facing a denial for a covered service should expect charges capped at the negotiated rate plus 20%, rather than potentially higher billed amounts.
• Payments made for denied services will count toward deductible, potentially accelerating deductible satisfaction.
• Patients may still encounter out-of-network costs if their plan does not cover out-of-network services or if the plan’s terms allow it.

Definitions and Key Terms (from the bill)

• denied coverage for procedural reasons
• covered benefit
• enrollee
• health plan
• negotiated provider payment
• deductible
• out-of-network
• provider contract
• Minnesota Statutes chapter 62Q

Relevant Terms - denied coverage - procedural reasons - covered benefit - enrollee - health plan - negotiated provider payment - plus 20 percent - deductible - out-of-network - provider contract - Minnesota Statutes Chapter 62Q