Purpose

This bill requires health plan companies to count amounts paid by the enrollee or paid on the enrollee’s behalf by another person when figuring the enrollee’s total contribution toward the out-of-pocket maximum and toward cost-sharing requirements. The rule applies to Minnesota health plans to the extent allowed by federal law, and updates Minnesota Statutes chapter 62Q, section 62Q.491.

Main Provisions

• For calculating an enrollee’s overall contribution toward any out-of-pocket maximum or cost-sharing requirement, the health plan must include amounts paid by the enrollee or paid on the enrollee’s behalf by another person.
• The term cost sharing is defined to include copayments, coinsurance, and deductibles.
• The requirement is limited to the extent permitted by federal law.

How it Changes Law (Significant Changes)

• Broadens what counts as contributing toward the enrollee’s out-of-pocket costs by including payments made by others on the enrollee’s behalf.
• Potentially affects when the out-of-pocket maximum is reached and how much the enrollee pays in cost sharing, depending on third-party payments.
• Codifies this requirement within Minnesota Statutes chapter 62Q, aligning state law with the new calculation standard, while recognizing federal-law limitations.

Definitions and Key Terms

• enrollee
• out-of-pocket maximum
• cost sharing
• copayment
• coinsurance
• deductible
• health plan / health plan company
• Minnesota Statutes chapter 62Q
• third-party payment / payments on behalf of the enrollee

Practical Implications

• Enrollees may see changes in how their total costs toward an OOP maximum are calculated if family members, caregivers, or others pay costs on the enrollee’s behalf.
• Insurers must apply this calculation method consistently, as long as federal law allows.

Relevant Terms - enrollee - out-of-pocket maximum - cost-sharing - copayment - coinsurance - deductible - health plan - health plan company - Minnesota Statutes chapter 62Q - 62Q.491 - third-party payment - payments on behalf of the enrollee - federal law