HF2555

HF2555 (Legislative Session 94 (2025-2026))

State employee group insurance program utilization review pilot program established, and reports required.

Related bill: SF3123

AI Generated Summary

Purpose of the Bill

The bill seeks to establish a pilot program to evaluate a new way of approving healthcare services for state employees in Minnesota. The aim is to compare the effectiveness, cost, and benefits of two different healthcare service approval methods: retrospective utilization review and prior authorization.

Main Provisions of the Bill

Pilot Program Establishment: A pilot program will be run from January 1, 2026, to December 31, 2030. During this period, health plans will use retrospective utilization review to assess the necessity and appropriateness of healthcare services for state employees. They may also use prior authorization but are not required to do so.
Quality and Payment Audits: Health carriers are required to conduct audits to compare these two review methods in terms of their impact on access to medically necessary care and on payments to healthcare providers.
Payment Provisions: If a decision is made that a healthcare service was not necessary (adverse determination), health carriers do not have to pay for those services. Healthcare providers cannot charge the enrollee for services not covered due to an adverse determination.
Program Termination Criteria: The program can be terminated if it negatively affects access to necessary healthcare or increases costs for enrollees or the state. Notice of intent to terminate must be given by July 1 of the prior year.

Significant Changes to Existing Law

The pilot program introduces retrospective utilization review as a new method for evaluating healthcare services, which is not currently standard in state employee health plans.
The bill specifies conditions and procedures under which healthcare services can be denied payment, potentially changing how disputes over medical necessity are resolved.

Relevant Terms

State Employee Group Insurance Program
Utilization Review
Retrospective Utilization Review
Prior Authorization
Medically Necessary Care
Health Carrier
Adverse Determination
Quality and Payment Audits
Healthcare Costs and Access

Bill text versions

Introduction PDF file

Actions

Date	Chamber	Where	Type	Name	Committee Name
March 19, 2025	House	Floor	Action	Introduction and first reading, referred to	State Government Finance and Policy
March 23, 2025	House	Floor	Action	Author added
March 23, 2025	House	Floor	Action	Author added

Citations

[
  {
    "analysis": {
      "added": [
        "Establishment of utilization review program for state employees."
      ],
      "removed": [
        "No direct removals from this chapter, used for defining terms."
      ],
      "summary": "The bill references Minnesota Statutes chapter 62C which pertains to nonprofit health service plan corporations.",
      "modified": [
        "Defines 'health carrier' as applicable under this chapter."
      ]
    },
    "citation": "62C"
  },
  {
    "analysis": {
      "added": [
        "Establishment of utilization review program for state employees."
      ],
      "removed": [
        "No direct removals from this chapter, used for defining terms."
      ],
      "summary": "The bill references Minnesota Statutes chapter 62D which pertains to health maintenance organizations.",
      "modified": [
        "Defines 'health carrier' as applicable under this chapter."
      ]
    },
    "citation": "62D"
  },
  {
    "analysis": {
      "added": [
        "Utilization review program considers 'health plan' definitions."
      ],
      "removed": [
        "No direct removals, only references definition."
      ],
      "summary": "Defines 'health plan' under the Minnesota Statutes section 62A.011, subdivision 3.",
      "modified": [
        "References 'health plan' for applicability in the program."
      ]
    },
    "citation": "62A.011"
  },
  {
    "analysis": {
      "added": [
        "Utilization review uses 'medically necessary care' standard."
      ],
      "removed": [
        "No direct removals, relies on existing definitions."
      ],
      "summary": "Provides the definition of 'medically necessary care' under Minnesota Statutes section 62Q.53, subdivision 2.",
      "modified": [
        "Defines standards for care evaluation in the pilot program."
      ]
    },
    "citation": "62Q.53"
  },
  {
    "analysis": {
      "added": [
        "Pilot program applies 'prior authorization' procedures."
      ],
      "removed": [
        "No direct removals, only employs existing standards."
      ],
      "summary": "Defines 'prior authorization' under Minnesota Statutes section 62M.02, subdivision 15.",
      "modified": [
        "Incorporates 'prior authorization' into program methodology."
      ]
    },
    "citation": "62M.02"
  },
  {
    "analysis": {
      "added": [
        "Usage of chapter 62M for retrospective and prior authorization review."
      ],
      "removed": [
        "No direct changes to chapter, follows existing rules."
      ],
      "summary": "The bill requires adherence to utilization review requirements and timelines outlined in Minnesota Statutes chapter 62M.",
      "modified": [
        "Utilization review timelines and requirements are applied."
      ]
    },
    "citation": "62M"
  },
  {
    "analysis": {
      "added": [
        "Pilot program established for health plan evaluation."
      ],
      "removed": [
        "No direct removals, existing program utilized for the pilot."
      ],
      "summary": "References the state employee group insurance program definitions and regulations under these sections.",
      "modified": [
        "Evaluates efficacy of insurance structuring under these statutes."
      ]
    },
    "citation": "43A.22 to 43A.31"
  }
]