SF 4354

Introduction - 94th Legislature (2025 - 2026)

Posted on 03/18/2026 09:18 a.m.

A bill for an act
relating to human services; modifying program integrity requirements for the
medical assistance program; directing the commissioner of human services to
create a medical assistance program integrity advisory board; directing the
commissioner of human services to make recommendations on provider enrollment
standards, modernizing program integrity infrastructure, and program integrity
interventions; directing the commissioner of human services to conduct audits;
requiring reports; appropriating money; amending Minnesota Statutes 2024, sections
245.095, by adding a subdivision; 256B.064, subdivisions 1b, 1d, 2, 3, 4, 5, by
adding subdivisions; Minnesota Statutes 2025 Supplement, sections 15.013, by
adding a subdivision; 256B.064, subdivision 1a.

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

Section 1.

Minnesota Statutes 2025 Supplement, section 15.013, is amended by adding a
subdivision to read:

new text begin Subd. 7. new text end

new text begin Exemption. new text end

new text begin This section does not apply to the medical assistance program
administered by the commissioner of human services.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 2.

Minnesota Statutes 2024, section 245.095, is amended by adding a subdivision to
read:

new text begin Subd. 7. new text end

new text begin Exemption. new text end

new text begin Subdivision 5 does not apply to any individual or entity that receives
payments from medical assistance or provides goods or services for which payment is made
from medical assistance.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 3.

Minnesota Statutes 2025 Supplement, section 256B.064, subdivision 1a, is amended
to read:

Subd. 1a.

Grounds for sanctions.

(a) The commissioner may impose sanctions against
any individual or entity that receives payments from medical assistance or provides goods
or services for which payment is made from medical assistance for any of the following:

(1) fraud, theft, or abuse in connection with the provision of goods and services to
recipients of public assistance for which payment is made from medical assistance;

(2) a pattern of presentment of false or duplicate claims or claims for services not
medically necessary;

(3) a pattern of making false statements of material facts for the purpose of obtaining
greater compensation than that to which the individual or entity is legally entitled;

(4) suspension or termination as a Medicare vendor;

(5) refusal to grant the state agency access during regular business hours to examine all
records necessary to disclose the extent of services provided to program recipients and
appropriateness of claims for payment;

(6) failure to repay an overpayment or a fine finally established under this section;

(7) failure to correct errors in the maintenance of health service or financial records for
which a fine was imposed or after issuance of a warning by the commissioner; and

(8) any reason for which an individual or entity could be excluded from participation in
the Medicare program under section 1128, 1128A, or 1866(b)(2) of the Social Security Act.

(b) For the purposes of this section, goods or services for which payment is made from
medical assistance includes but is not limited to care and services identified in section
256B.0625 or provided pursuant to any federally approved waiver.

(c) Regardless of the source of payment or other item of value, the commissioner may
impose sanctions against any individual or entity that solicits, receives, pays, or offers to
pay any illegal remuneration as described in section 142E.51, subdivision 6a, in violation
of section 609.542, subdivision 2, or in violation of United States Code, title 42, section
1320a-7b(b)(1) or (2). No conviction is required before the commissioner can impose
sanctions under this paragraph.

(d) The commissioner may impose sanctions against a pharmacy provider for failure to
respond to a cost of dispensing survey under section 256B.0625, subdivision 13e, paragraph
(g).

(e) The commissioner may impose sanctions against a pharmacy provider for failure to
respond to a Minnesota drug acquisition cost survey under section 256B.0625, subdivision
13e, paragraph (i).

new text begin (f) For the purposes of this section, "abuse" means the activities listed in paragraph (a),
clauses (2), (3), and (7), but does not include billing errors that result in unintended
overcharges.
new text end

Sec. 4.

Minnesota Statutes 2024, section 256B.064, subdivision 1b, is amended to read:

Subd. 1b.

Sanctions available.

new text begin (a) new text end The commissioner may impose the following sanctions
for the conduct described in subdivision 1a: deleted text begin suspension or withholding of deleted text end new text begin suspending new text end
payments to an individual or entity deleted text begin and deleted text end new text begin ; withholding payments to an individual or entity; new text end
suspending deleted text begin or terminating deleted text end participation in the program deleted text begin , deleted text end new text begin ; terminating participation in the
program; new text end or deleted text begin imposition of deleted text end new text begin imposing new text end a fine under subdivision deleted text begin 2, paragraph (g) deleted text end new text begin 2a new text end .

new text begin (b) new text end When imposing sanctions under this deleted text begin section deleted text end new text begin subdivision new text end , the commissioner deleted text begin shall deleted text end new text begin
must new text end consider the nature, chronicity, or severity of the conduct and the effect of the conduct
on the health and safety of persons served by the individual or entity.

new text begin (c) new text end The commissioner deleted text begin shall deleted text end new text begin must new text end suspend an individual's or entity's participation in the
program for a minimum of five years if the individual or entity is convicted of a crime,
received a stay of adjudication, or entered a court-ordered diversion program for an offense
related to a provision of a health service under medical assistance, including a federally
approved waiver, or health care fraud.

new text begin (d) new text end Regardless of imposition of sanctions, the commissioner may make a referral to the
appropriate state licensing board.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 5.

Minnesota Statutes 2024, section 256B.064, subdivision 1d, is amended to read:

Subd. 1d.

Investigative costs.

new text begin (a) new text end The commissioner may seek recovery of investigative
costs from any individual or entity that willfully submits a claim for reimbursement for
services that the individual or entity knows, or reasonably should have known, is a false
representation and that results in the payment of public funds for which the individual or
entity is ineligible.

new text begin (b) new text end Billing errors that result in unintentional overcharges deleted text begin shall deleted text end new text begin are new text end not deleted text begin be deleted text end grounds for
investigative cost recoupment.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 6.

Minnesota Statutes 2024, section 256B.064, subdivision 2, is amended to read:

Subd. 2.

Imposition of monetary recovery and sanctions new text begin ; generally new text end .

(a) The
commissioner deleted text begin shall deleted text end new text begin must new text end determine any monetary amounts to be recovered and sanctions
to be imposed upon an individual or entity under this section. Except as provided in
deleted text begin paragraphs (b) and (d), neither deleted text end new text begin subdivisions 2b to 2d, the commissioner must not obtain new text end a
monetary recovery deleted text begin nor deleted text end new text begin or impose new text end a sanction deleted text begin will be imposed by the commissioner deleted text end without
prior notice and an opportunity for a hearing, according to chapter 14, on the commissioner's
proposed action deleted text begin , provided that the commissioner may suspend or reduce payment to an
individual or entity, except a nursing home or convalescent care facility, after notice and
prior to the hearing if in the commissioner's opinion that action is necessary to protect the
public welfare and the interests of the program deleted text end .

deleted text begin (b) Except when the commissioner finds good cause not to suspend payments under
Code of Federal Regulations, title 42, section 455.23(e) or (f), the commissioner shall
withhold or reduce payments to an individual or entity without providing advance notice
of such withholding or reduction if either of the following occurs:
deleted text end

deleted text begin (1) the individual or entity is convicted of a crime involving the conduct described in
subdivision 1a; or
deleted text end

deleted text begin (2) the commissioner determines there is a credible allegation of fraud for which an
investigation is pending under the program. Allegations are considered credible when they
have an indicium of reliability and the state agency has reviewed all allegations, facts, and
evidence carefully and acts judiciously on a case-by-case basis. A credible allegation of
fraud is an allegation which has been verified by the state, from any source, including but
not limited to:
deleted text end

deleted text begin (i) fraud hotline complaints;
deleted text end

deleted text begin (ii) claims data mining; and
deleted text end

deleted text begin (iii) patterns identified through provider audits, civil false claims cases, and law
enforcement investigations.
deleted text end

deleted text begin (c) The commissioner must send notice of the withholding or reduction of payments
under paragraph (b) within five days of taking such action unless requested in writing by a
law enforcement agency to temporarily withhold the notice. The notice must:
deleted text end

deleted text begin (1) state that payments are being withheld according to paragraph (b);
deleted text end

deleted text begin (2) set forth the general allegations as to the nature of the withholding action, but need
not disclose any specific information concerning an ongoing investigation;
deleted text end

deleted text begin (3) except in the case of a conviction for conduct described in subdivision 1a, state that
the withholding is for a temporary period and cite the circumstances under which withholding
will be terminated;
deleted text end

deleted text begin (4) identify the types of claims to which the withholding applies; and
deleted text end

deleted text begin (5) inform the individual or entity of the right to submit written evidence for consideration
by the commissioner.
deleted text end

deleted text begin (d) The withholding or reduction of payments will not continue after the commissioner
determines there is insufficient evidence of fraud by the individual or entity, or after legal
proceedings relating to the alleged fraud are completed, unless the commissioner has sent
notice of intention to impose monetary recovery or sanctions under paragraph (a). Upon
conviction for a crime related to the provision, management, or administration of a health
service under medical assistance, a payment held pursuant to this section by the commissioner
or a managed care organization that contracts with the commissioner under section 256B.035
is forfeited to the commissioner or managed care organization, regardless of the amount
charged in the criminal complaint or the amount of criminal restitution ordered.
deleted text end

deleted text begin (e) The commissioner shall suspend or terminate an individual's or entity's participation
in the program without providing advance notice and an opportunity for a hearing when the
suspension or termination is required because of the individual's or entity's exclusion from
participation in Medicare. Within five days of taking such action, the commissioner must
send notice of the suspension or termination. The notice must:
deleted text end

deleted text begin (1) state that suspension or termination is the result of the individual's or entity's exclusion
from Medicare;
deleted text end

deleted text begin (2) identify the effective date of the suspension or termination; and
deleted text end

deleted text begin (3) inform the individual or entity of the need to be reinstated to Medicare before
reapplying for participation in the program.
deleted text end

deleted text begin (f) deleted text end new text begin (b) new text end Upon receipt of a notice under paragraph (a) new text begin or subdivision 2c or 2d new text end that a
monetary recovery or sanction is to be new text begin or has been new text end imposed, an individual or entity may
request a contested case, as defined in section 14.02, subdivision 3, by filing with the
commissioner a written request of appeal. The appeal request must be received by the
commissioner no later than 30 days after the date the notification of monetary recovery or
sanction was mailed to the individual or entity. The appeal request must specify:

(1) each disputed item, the reason for the dispute, and an estimate of the dollar amount
involved for each disputed item;

(2) the computation that the individual or entity believes is correct;

(3) the authority in statute or rule upon which the individual or entity relies for each
disputed item;

(4) the name and address of the person or entity with whom contacts may be made
regarding the appeal; and

(5) other information required by the commissioner.

deleted text begin (g) The commissioner may order an individual or entity to forfeit a fine for failure to
fully document services according to standards in this chapter and Minnesota Rules, chapter
deleted text end deleted text begin 9505 deleted text end deleted text begin . The commissioner may assess fines if specific required components of documentation
are missing. The fine for incomplete documentation shall equal 20 percent of the amount
paid on the claims for reimbursement submitted by the individual or entity, or up to $5,000,
whichever is less. If the commissioner determines that an individual or entity repeatedly
violated this chapter, chapter deleted text end deleted text begin 254B deleted text end deleted text begin or deleted text end deleted text begin 245G deleted text end deleted text begin , or Minnesota Rules, chapter deleted text end deleted text begin 9505 deleted text end deleted text begin , related to
the provision of services to program recipients and the submission of claims for payment,
the commissioner may order an individual or entity to forfeit a fine based on the nature,
severity, and chronicity of the violations, in an amount of up to $5,000 or 20 percent of the
value of the claims, whichever is greater.
deleted text end

deleted text begin (h) The individual or entity shall pay the fine assessed on or before the payment date
specified. If the individual or entity fails to pay the fine, the commissioner may withhold
or reduce payments and recover the amount of the fine. A timely appeal shall stay payment
of the fine until the commissioner issues a final order.
deleted text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 7.

Minnesota Statutes 2024, section 256B.064, is amended by adding a subdivision
to read:

new text begin Subd. 2a. new text end

new text begin Imposition of fines. new text end

new text begin (a) The commissioner may order an individual or entity
to forfeit a fine for failure to fully document services according to standards in this chapter
and Minnesota Rules, chapter 9505. The commissioner may assess fines if specific required
components of documentation are missing. The fine for incomplete documentation equals
20 percent of the amount paid on the claims for reimbursement submitted by the individual
or entity, or up to $5,000, whichever is less. If the commissioner determines that an individual
or entity repeatedly violated this chapter, chapter 245G or 254B, or Minnesota Rules, chapter
9505, related to the provision of services to program recipients and the submission of claims
for payment, the commissioner may order an individual or entity to forfeit a fine based on
the nature, severity, and chronicity of the violations, in an amount of up to $5,000 or 20
percent of the value of the claims, whichever is greater.
new text end

new text begin (b) The individual or entity must pay the fine assessed on or before the payment date
specified by the commissioner. If the individual or entity fails to pay the fine, the
commissioner may withhold or reduce payments and recover the amount of the fine. A
timely appeal stays payment of the fine until the commissioner issues a final order.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 8.

Minnesota Statutes 2024, section 256B.064, is amended by adding a subdivision
to read:

new text begin Subd. 2b. new text end

new text begin Mandatory suspension or termination after exclusion from participation
in Medicare. new text end

new text begin (a) The commissioner must suspend or terminate an individual's or entity's
participation in the program without providing advance notice and an opportunity for a
hearing when the suspension or termination is required because of the individual's or entity's
exclusion from participation in Medicare.
new text end

new text begin (b) Within five days of taking an action under paragraph (a), the commissioner must
send notice of the suspension or termination. The notice must:
new text end

new text begin (1) state that the suspension or termination is the result of the individual's or entity's
exclusion from Medicare;
new text end

new text begin (2) identify the effective date of the suspension or termination; and
new text end

new text begin (3) inform the individual or entity of the need to be reinstated to Medicare before
reapplying for participation in the program.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 9.

Minnesota Statutes 2024, section 256B.064, is amended by adding a subdivision
to read:

new text begin Subd. 2c. new text end

new text begin Imposition of monetary recovery and sanctions before a hearing. new text end

new text begin (a) Except
as provided in paragraph (b), the commissioner may withhold or reduce payment to an
individual or entity after notice but before a hearing if, in the commissioner's opinion,
withholding or reducing payment is necessary to protect the public welfare and the interests
of the program.
new text end

new text begin (b) The commissioner must not withhold or reduce payments to a nursing home or
convalescent care facility before a hearing.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 10.

Minnesota Statutes 2024, section 256B.064, is amended by adding a subdivision
to read:

new text begin Subd. 2d. new text end

new text begin Imposition of monetary recovery and sanctions without prior notice. new text end

new text begin (a)
Except when the commissioner finds good cause not to suspend payments under Code of
Federal Regulations, title 42, section 455.23(e) or (f), the commissioner must withhold or
reduce payments to an individual or entity without providing advance notice of the
withholding or reduction if either of the following occurs:
new text end

new text begin (1) the individual or entity is convicted of a crime involving the conduct described in
subdivision 1a; or
new text end

new text begin (2) the commissioner determines there is a credible allegation of fraud for which an
investigation is pending under the program. Allegations are considered credible when they
are supported by a preponderance of the evidence and the state agency has reviewed all
allegations, facts, and evidence carefully and acts judiciously on a case-by-case basis. A
credible allegation of fraud is an allegation supported by a preponderance of the evidence
that has been verified by the state, from any source, including but not limited to:
new text end

new text begin (i) fraud hotline complaints;
new text end

new text begin (ii) claims data mining; and
new text end

new text begin (iii) patterns identified through provider audits, civil false claims cases, and law
enforcement investigations.
new text end

new text begin (b) The commissioner must send notice of the withholding or reduction of payments
under paragraph (a) within five days of withholding or reducing payment unless requested
in writing by a law enforcement agency to temporarily withhold the notice. The notice need
not disclose specific information concerning an ongoing investigation. The notice must:
new text end

new text begin (1) state that payments are being withheld according to paragraph (a);
new text end

new text begin (2) set forth the allegations as to the nature of the withholding action, which must specify:
new text end

new text begin (i) each disputed item, and for each disputed item the reason for the dispute and an
estimate of the dollar amount involved;
new text end

new text begin (ii) the computation that the commissioner believes is correct;
new text end

new text begin (iii) the statute or rule the commissioner believes the individual or entity violated; and
new text end

new text begin (iv) other information necessary to aid the individual or entity when providing written
evidence under clause (5) or filing an appeal under section 256B.064, subdivision 2;
new text end

new text begin (3) except in the case of a conviction for conduct described in subdivision 1a, state that
the withholding is for a temporary period not to exceed 60 days and cite the circumstances
under which withholding will be terminated;
new text end

new text begin (4) identify the types of claims to which the withholding applies; and
new text end

new text begin (5) inform the individual or entity of the right to submit written evidence for consideration
by the commissioner.
new text end

new text begin (c) The commissioner must cease to withhold or reduce payments under this subdivision
after 60 days have passed, after the commissioner determines there is insufficient evidence
of fraud by the individual or entity, or after legal proceedings relating to the alleged fraud
are completed, unless the commissioner has sent notice of intention to impose monetary
recovery or sanctions.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 11.

Minnesota Statutes 2024, section 256B.064, is amended by adding a subdivision
to read:

new text begin Subd. 2e. new text end

new text begin Forfeiture of withheld payments upon criminal conviction. new text end

new text begin Upon conviction
for a crime related to the provision, management, or administration of a health service under
medical assistance, a payment held pursuant to this section by the commissioner or a managed
care organization that contracts with the commissioner under section 256B.035 is forfeited
to the commissioner or managed care organization, regardless of the amount charged in the
criminal complaint or the amount of criminal restitution ordered.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 12.

Minnesota Statutes 2024, section 256B.064, subdivision 3, is amended to read:

Subd. 3.

Mandates on prohibited payments.

(a) The commissioner deleted text begin shall deleted text end new text begin must new text end maintain
and publish a list of each excluded individual and entity that was convicted of a crime related
to the provision, management, or administration of a medical assistance health service, or
suspended or terminated under subdivision deleted text begin 2 deleted text end new text begin 2b new text end . Medical assistance payments cannot be
made by an individual or entity for items or services furnished either directly or indirectly
by an excluded individual or entity, or at the direction of excluded individuals or entities.

(b) The entity must check the exclusion list on a monthly basis and document the date
and time the exclusion list was checked and the name and title of the person who checked
the exclusion list. The entity must immediately terminate payments to an individual or entity
on the exclusion list.

(c) An entity's requirement to check the exclusion list and to terminate payments to
individuals or entities on the exclusion list applies to each individual or entity on the
exclusion list, even if the named individual or entity is not responsible for direct patient
care or direct submission of a claim to medical assistance.

(d) An entity that pays medical assistance program funds to an individual or entity on
the exclusion list must refund any payment related to either items or services rendered by
an individual or entity on the exclusion list from the date the individual or entity is first paid
or the date the individual or entity is placed on the exclusion list, whichever is later, and an
entity may be subject to:

(1) sanctions under deleted text begin subdivision 2 deleted text end new text begin this section new text end ;

(2) a civil monetary penalty of up to $25,000 for each determination by the department
that the vendor employed or contracted with an individual or entity on the exclusion list;
and

(3) other fines or penalties allowed by law.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 13.

Minnesota Statutes 2024, section 256B.064, subdivision 4, is amended to read:

Subd. 4.

Notice.

(a) The department deleted text begin shall deleted text end new text begin must new text end serve the notice required under deleted text begin subdivision deleted text end new text begin
subdivisions new text end 2 new text begin and 2d new text end using a signature-verified confirmed delivery method to the address
submitted to the department by the individual or entity. Service is complete upon mailing.

(b) The department deleted text begin shall deleted text end new text begin must new text end give notice in writing to a recipient placed in the Minnesota
restricted recipient program under section 256B.0646 and Minnesota Rules, part 9505.2200.
The department deleted text begin shall deleted text end new text begin must new text end send the notice by first class mail to the recipient's current address
on file with the department. A recipient placed in the Minnesota restricted recipient program
may contest the placement by submitting a written request for a hearing to the department
within 90 days of the notice being mailed.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 14.

Minnesota Statutes 2024, section 256B.064, subdivision 5, is amended to read:

Subd. 5.

Immunity; good faith reporters.

(a) A person who makes a good faith report
is immune from any civil or criminal liability that might otherwise arise from reporting or
participating in the investigation. Nothing in this subdivision affects an individual's or
entity's responsibility for an overpayment established under this subdivision.

(b) A person employed by a lead investigative agency who is conducting or supervising
an investigation or enforcing the law according to the applicable law or rule is immune from
any civil or criminal liability that might otherwise arise from the person's actions, if the
person is acting in good faith and exercising due care.

(c) For purposes of this subdivision, "person" includes a natural person or any form of
a business or legal entity.

(d) After an investigation is complete, the reporter's name must be kept confidential.
The subject of the report may compel disclosure of the reporter's name only with the consent
of the reporter or upon a written finding by a district court that the report was false and there
is evidence that the report was made in bad faith. This subdivision does not alter disclosure
responsibilities or obligations under the Rules of Criminal Procedure, except that when the
identity of the reporter is relevant to a criminal prosecution the district court deleted text begin shall deleted text end new text begin must new text end
conduct an in-camera review before determining whether to order disclosure of the reporter's
identity.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective the day following final enactment.
new text end

Sec. 15. new text begin DIRECTION TO COMMISSIONER OF HUMAN SERVICES; MEDICAL
ASSISTANCE PROGRAM INTEGRITY ADVISORY BOARD.
new text end

new text begin (a) By January 1, 2027, the commissioner of human services must establish a medical
assistance program integrity advisory board. The board must oversee medical assistance
program integrity efforts, evaluate the efforts, and provide recommendations, including but
not limited to legislative changes, to the commissioner on ways to improve medical assistance
program integrity. The board must advise the commissioner on enforcement proportionality,
analytics governance, and program integrity metrics.
new text end

new text begin (b) The board must consist of seven members appointed by the commissioner of human
services and must include:
new text end

new text begin (1) at least one member who is a forensic accountant;
new text end

new text begin (2) at least one member who is a data scientist;
new text end

new text begin (3) at least one member who is a long-term services and supports program expert;
new text end

new text begin (4) at least one member who is a program design and evaluation specialist; and
new text end

new text begin (5) at least one member of the public.
new text end

new text begin (c) The commissioner must annually select a board chair from among the members. The
commissioner must develop procedures for appointing new members, compensation for
members, and term length, if any, for members.
new text end

Sec. 16. new text begin DIRECTION TO COMMISSIONER OF HUMAN SERVICES; MEDICAL
ASSISTANCE PROVIDER ENROLLMENT STANDARDS.
new text end

new text begin (a) By January 1, 2027, the commissioner of human services must make recommendations
to the chairs and ranking minority members of the legislative committees with jurisdiction
over human services policy and finance regarding statutory and program changes to ensure
only qualified, prepared, and financially stable providers are permitted to enroll as a medical
assistance provider type designated by the commissioner as high-risk under Minnesota
Statutes, section 256B.04, subdivision 21.
new text end

new text begin (b) The commissioner must include in the recommendations enhanced provider enrollment
screening standards related to the provider's regulatory knowledge, operational readiness,
internal controls, financial liquidity and solvency, and capacity to comply with state and
federal Medicaid requirements.
new text end

new text begin (c) In developing the recommendations, the commissioner must consult with the Health
Law Section of the Minnesota State Bar Association, representatives of the medical assistance
providers subject to the recommendations being considered, and other impacted groups.
new text end

Sec. 17. new text begin DIRECTION TO COMMISSIONER OF HUMAN SERVICES; PROGRAM
INTEGRITY TECHNOLOGY MODERNIZATION.
new text end

new text begin By January 1, 2027, the commissioner of human services must develop recommendations
on how to modernize program integrity infrastructure within the Department of Human
Services. The recommendations must include the infrastructure's capability to provide
near-real-time analytics and risk scoring; prepayment review and anomaly detection;
cross-matching of enrollment data, licensure data, and claims data; and security dashboards
for audits and investigations with privacy safeguards. By January 15, 2027, the commissioner
must provide recommendations to the chairs and ranking minority members of the legislative
committees with jurisdiction over human services program integrity functions.
new text end

Sec. 18. new text begin DIRECTION TO COMMISSIONER OF HUMAN SERVICES; PROGRAM
STRUCTURE AND DESIGN AUDITS.
new text end

new text begin (a) By August 1, 2026, the commissioner of human services must select and contract
with an independent research entity to conduct comprehensive program structure and design
audits on the services listed in paragraph (b). Each audit must identify structural incentive
misalignments; undue compliance burdens on good-faith providers; regulatory and billing
ambiguities; and gaps in utilization controls. Each audit must also provide evidence-based
redesign recommendations.
new text end

new text begin (b) The services that must be audited by the independent research entity include:
new text end

new text begin (1) adult companion services;
new text end

new text begin (2) adult day services;
new text end

new text begin (3) adult rehabilitative mental health services;
new text end

new text begin (4) assertive community treatment;
new text end

new text begin (5) community first services and supports;
new text end

new text begin (6) early intensive developmental and behavioral intervention;
new text end

new text begin (7) individualized home supports;
new text end

new text begin (8) integrated community supports;
new text end

new text begin (9) intensive residential treatment services;
new text end

new text begin (10) night supervision services;
new text end

new text begin (11) nonemergency medical transportation services;
new text end

new text begin (12) peer recovery support services; and
new text end

new text begin (13) recuperative care.
new text end

new text begin (c) Each audit must be completed by January 1, 2027. The commissioner must submit
each completed audit report within 30 days of receipt to the chairs and ranking minority
members of the legislative committees with jurisdiction over human services program
integrity functions.
new text end

Sec. 19. new text begin DIRECTION TO COMMISSIONER OF HUMAN SERVICES;
PROPORTIONAL MEDICAL ASSISTANCE PROGRAM INTEGRITY
INTERVENTIONS.
new text end

new text begin (a) By January 1, 2027, the commissioner of human services must make recommendations
to the chairs and ranking minority members of the legislative committees with jurisdiction
over human services policy and finance on modernizing medical assistance program integrity
efforts to strengthen fraud deterrence and promote clarity, proportionality based on the
severity of an infraction, provider education, client protection, and continuity of care.
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new text begin (b) The commissioner must include in the recommendations a comprehensive approach
to proportional medical assistance program integrity interventions commensurate with the
severity of an infraction of a medical assistance program requirement.
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new text begin (c) For the purposes of the recommendations, the commissioner must consider three
levels of severity:
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new text begin (1) low-severity conduct, which includes clerical or documentation deficiencies with no
evidence of intent to defraud;
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new text begin (2) moderate-severity conduct, which includes repeat errors, evidence of weak internal
controls, or other behavior that results in a pattern of improper payment; and
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new text begin (3) high-severity conduct, which includes intentional actions by a provider to defraud
and gain unearned payment.
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new text begin (d) For the purposes of the recommendations, the commissioner must consider three
levels of intervention:
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new text begin (1) provider education for low-severity conduct;
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new text begin (2) targeted audits for moderate-severity conduct; and
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new text begin (3) suspended provider enrollment for high-severity conduct.
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new text begin (e) In developing the recommendations, the commissioner must consult with the Health
Law Section of the Minnesota State Bar Association, representatives of the medical assistance
providers subject to the recommendations being considered, and other impacted groups.
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Sec. 20. new text begin APPROPRIATION; MINNESOTA ATTORNEY GENERAL.
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new text begin $391,000 in fiscal year 2027 is appropriated from the general fund to the attorney general
to increase the number of staff within the Medicaid Fraud Control Unit to improve program
integrity and increase the Medical Fraud Control Unit's capacity for compliance efforts.
new text end