1.1 A bill for an act
1.2 relating to state government; establishing a state employee group insurance program
1.3 utilization review pilot program; requiring reports.
1.4BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:
1.5 Section 1. STATE EMPLOYEE GROUP INSURANCE PROGRAM UTILIZATION
1.6REVIEW PILOT PROGRAM.
1.7 Subdivision 1.Definitions.(a) For purposes of this section, the following terms have
1.8the meanings given.
1.9 (b) "Enrollee" means an individual covered by a health plan offered through the state
1.10employee group insurance program.
1.11 (c) "Health carrier" means a nonprofit health service plan corporation operating under
1.12Minnesota Statutes, chapter 62C, or health maintenance organization operating under
1.13Minnesota Statutes, chapter 62D, with which the commissioner of management and budget
1.14contracts for purposes of the state employee group insurance program.
1.15 (d) "Health plan" means a health plan as defined in Minnesota Statutes, section 62A.011,
1.16subdivision 3, that is offered through the state employee group insurance program.
1.17 (e) "Medically necessary care" has the meaning given in Minnesota Statutes, section
1.1862Q.53, subdivision 2.
1.19 (f) "Prior authorization" has the meaning given in Minnesota Statutes, section 62M.02,
1.20subdivision 15.
1Section 1.
REVISOR SS/ES 25-0411103/06/25
State of Minnesota
This Document can be made available
in alternative formats upon request
HOUSE OF REPRESENTATIVES
H. F. No. 2555
NINETY-FOURTH SESSION
Authored by Nadeau, Bierman, Liebling and Backer03/20/2025
The bill was read for the first time and referred to the Committee on State Government Finance and Policy 2.1 (g) "Retrospective utilization review" means the evaluation, after the provision of a
2.2service or procedure or facility admission, of the necessity, appropriateness, and efficacy
2.3of the health care service or procedure or facility admission by an individual or entity other
2.4than the attending health care professional.
2.5 (h) "State employee group insurance program" means the state employee group insurance
2.6program under Minnesota Statutes, sections 43A.22 to 43A.31.
2.7 Subd. 2.Pilot program established.The commissioner of management and budget
2.8must establish and administer a utilization review pilot program under the state employee
2.9group insurance program between January 1, 2026, and December 31, 2030, to evaluate the
2.10efficacy, costs, and benefits of using retrospective utilization review as compared with using
2.11prior authorization to evaluate the necessity, appropriateness, and efficacy of health care
2.12services and procedures and facility admissions for enrollees. Under the pilot program,
2.13health plans must use retrospective utilization review, and may but are not required to use
2.14prior authorization, to evaluate the necessity, appropriateness, and efficacy of health care
2.15services and procedures and facility admissions for enrollees. Under the pilot program,
2.16retrospective utilization review and, if conducted, prior authorization must be conducted
2.17according to the requirements and timelines for utilization review in Minnesota Statutes,
2.18chapter 62M.
2.19 Subd. 3.Quality and payment audits.During the pilot program, health carriers must
2.20conduct quality and payment audits of retrospective utilization review determinations and
2.21prior authorization determinations made under the pilot program to evaluate the effects of
2.22the pilot program on enrollee access to medically necessary care and on payments to health
2.23care providers and facilities for health care services and procedures and facility admissions.
2.24 Subd. 4.Payment.(a) A health carrier may decline to pay a health care provider or
2.25facility for a health care service or procedure or facility admission for which an adverse
2.26determination is made and, if applicable, upheld on appeal.
2.27 (b) A health care provider or facility must not bill an enrollee or guarantor for, or
2.28otherwise seek to collect from an enrollee or guarantor, any amount for a health care service
2.29or procedure or facility admission for which the enrollee's health carrier made an adverse
2.30determination and that, if applicable, was upheld on appeal.
2.31 Subd. 5.Termination.The commissioner of management and budget may terminate
2.32the operation of the pilot program upon:
2.33 (1) a determination by the commissioner that the pilot program is having a significant
2.34negative impact on enrollee access to medically necessary care through the state employee
2Section 1.
REVISOR SS/ES 25-0411103/06/25 3.1group insurance program or on costs to enrollees or the state for health care provided through
3.2the state employee group insurance program; and
3.3 (2) provision of notice to health carriers and to the chairs and ranking minority members
3.4of the legislative committees with jurisdiction over state government and health care, of the
3.5commissioner's intent to terminate the operation of the pilot program. This notice must be
3.6provided by July 1 of the calendar year prior to the year in which the commissioner intends
3.7to terminate the pilot program.
3.8Upon satisfaction by the commissioner of the requirements in clauses (1) and (2), the pilot
3.9program shall cease operations on January 1 of the year following the year in which notice
3.10was provided under clause (2).
3.11 Subd. 6.Reports.The commissioner of management and budget, in collaboration with
3.12the commissioner of health, must:
3.13 (1) evaluate the impacts of the pilot program on the cost to enrollees and to the state for
3.14health care provided under the state employee group insurance program and on enrollee
3.15access to care and the quality of health care provided to enrollees;
3.16 (2) develop recommendations on whether to continue the pilot program or expand the
3.17pilot program to other populations; and
3.18 (3) issue reports on these impacts and recommendations to the legislative committees
3.19with jurisdiction over health care and state government by March 1, 2027, and March 1 of
3.20each year thereafter through March 1, 2031.
3Section 1.
REVISOR SS/ES 25-0411103/06/25