HF 2555

as introduced - 94th Legislature (2025 - 2026) Posted on 03/24/2025 04:16pm

A bill for an act
relating to state government; establishing a state employee group insurance program
utilization review pilot program; requiring reports.

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

Section 1. new text begin STATE EMPLOYEE GROUP INSURANCE PROGRAM UTILIZATION
REVIEW PILOT PROGRAM.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For purposes of this section, the following terms have
the meanings given.
new text end

new text begin (b) "Enrollee" means an individual covered by a health plan offered through the state
employee group insurance program.
new text end

new text begin (c) "Health carrier" means a nonprofit health service plan corporation operating under
Minnesota Statutes, chapter 62C, or health maintenance organization operating under
Minnesota Statutes, chapter 62D, with which the commissioner of management and budget
contracts for purposes of the state employee group insurance program.
new text end

new text begin (d) "Health plan" means a health plan as defined in Minnesota Statutes, section 62A.011,
subdivision 3, that is offered through the state employee group insurance program.
new text end

new text begin (e) "Medically necessary care" has the meaning given in Minnesota Statutes, section
62Q.53, subdivision 2.
new text end

new text begin (f) "Prior authorization" has the meaning given in Minnesota Statutes, section 62M.02,
subdivision 15.
new text end

new text begin (g) "Retrospective utilization review" means the evaluation, after the provision of a
service or procedure or facility admission, of the necessity, appropriateness, and efficacy
of the health care service or procedure or facility admission by an individual or entity other
than the attending health care professional.
new text end

new text begin (h) "State employee group insurance program" means the state employee group insurance
program under Minnesota Statutes, sections 43A.22 to 43A.31.
new text end

new text begin Subd. 2. new text end

new text begin Pilot program established. new text end

new text begin The commissioner of management and budget
must establish and administer a utilization review pilot program under the state employee
group insurance program between January 1, 2026, and December 31, 2030, to evaluate the
efficacy, costs, and benefits of using retrospective utilization review as compared with using
prior authorization to evaluate the necessity, appropriateness, and efficacy of health care
services and procedures and facility admissions for enrollees. Under the pilot program,
health plans must use retrospective utilization review, and may but are not required to use
prior authorization, to evaluate the necessity, appropriateness, and efficacy of health care
services and procedures and facility admissions for enrollees. Under the pilot program,
retrospective utilization review and, if conducted, prior authorization must be conducted
according to the requirements and timelines for utilization review in Minnesota Statutes,
chapter 62M.
new text end

new text begin Subd. 3. new text end

new text begin Quality and payment audits. new text end

new text begin During the pilot program, health carriers must
conduct quality and payment audits of retrospective utilization review determinations and
prior authorization determinations made under the pilot program to evaluate the effects of
the pilot program on enrollee access to medically necessary care and on payments to health
care providers and facilities for health care services and procedures and facility admissions.
new text end

new text begin Subd. 4. new text end

new text begin Payment. new text end

new text begin (a) A health carrier may decline to pay a health care provider or
facility for a health care service or procedure or facility admission for which an adverse
determination is made and, if applicable, upheld on appeal.
new text end

new text begin (b) A health care provider or facility must not bill an enrollee or guarantor for, or
otherwise seek to collect from an enrollee or guarantor, any amount for a health care service
or procedure or facility admission for which the enrollee's health carrier made an adverse
determination and that, if applicable, was upheld on appeal.
new text end

new text begin Subd. 5. new text end

new text begin Termination. new text end

new text begin The commissioner of management and budget may terminate
the operation of the pilot program upon:
new text end

new text begin (1) a determination by the commissioner that the pilot program is having a significant
negative impact on enrollee access to medically necessary care through the state employee
group insurance program or on costs to enrollees or the state for health care provided through
the state employee group insurance program; and
new text end

new text begin (2) provision of notice to health carriers and to the chairs and ranking minority members
of the legislative committees with jurisdiction over state government and health care, of the
commissioner's intent to terminate the operation of the pilot program. This notice must be
provided by July 1 of the calendar year prior to the year in which the commissioner intends
to terminate the pilot program.
new text end

new text begin Upon satisfaction by the commissioner of the requirements in clauses (1) and (2), the pilot
program shall cease operations on January 1 of the year following the year in which notice
was provided under clause (2).
new text end

new text begin Subd. 6. new text end

new text begin Reports. new text end

new text begin The commissioner of management and budget, in collaboration with
the commissioner of health, must:
new text end

new text begin (1) evaluate the impacts of the pilot program on the cost to enrollees and to the state for
health care provided under the state employee group insurance program and on enrollee
access to care and the quality of health care provided to enrollees;
new text end

new text begin (2) develop recommendations on whether to continue the pilot program or expand the
pilot program to other populations; and
new text end

new text begin (3) issue reports on these impacts and recommendations to the legislative committees
with jurisdiction over health care and state government by March 1, 2027, and March 1 of
each year thereafter through March 1, 2031.
new text end