SF3123

Purpose of the Bill

The bill establishes a pilot program to review the utilization of health care services for state employees in Minnesota. This program is designed to evaluate the use and effectiveness of retrospective utilization reviews compared to prior authorization procedures for health services covered by the state employee group insurance program.

Main Provisions

• Pilot Program Duration: The program will run from January 1, 2026, to December 31, 2030.
• Evaluation Methods: It will focus on using retrospective utilization reviews, while allowing, but not requiring, the use of prior authorizations.
• Quality and Payment Audits: Health carriers are tasked with conducting audits to assess the program's effect on access to medically necessary care and payment processes.
• Payment Rules: Health carriers can refuse payment for services if an adverse determination has been made and upheld on appeal. Health providers and facilities cannot bill enrollees for these services.
• Program Termination: The pilot can be terminated early if significantly negative impacts on access to necessary care or costs are identified.
• Reporting and Recommendations: The commissioner of management and budget, in partnership with the health commissioner, will report on the program's impacts and provide recommendations on its continuation or expansion. Reports are due annually beginning March 1, 2027, until March 1, 2031.

Significant Changes to Existing Law

This bill introduces a new framework for evaluating health care usage for state employees by integrating a pilot program focusing on retrospective utilization reviews. It modifies the existing approach which heavily relies on prior authorizations.

Relevant Terms

• State Employee Group Insurance
• Utilization Review
• Retrospective Review
• Prior Authorization
• Medically Necessary Care
• Health Carrier
• Quality and Payment Audits