Purpose of the Bill

This bill establishes a pilot program aimed at evaluating different methods of reviewing health care services for state employees in Minnesota. The focus is on comparing the effectiveness and costs of retrospective utilization review to prior authorization in assessing health care services provided through the state employee group insurance program.

Main Provisions

• Pilot Program Duration and Objective: The pilot program will run from January 1, 2026, to December 31, 2030. It will assess whether retrospective utilization reviews are more effective and cost-efficient than prior authorization in determining the necessity and appropriateness of health services for state employees.

• Methods of Utilization Review: Under the pilot program, health plans are required to use retrospective utilization review but are not required to use prior authorization. Both reviews will follow the established guidelines in Minnesota Statutes chapter 62M.

• Quality and Payment Audits: Health carriers are required to conduct audits on both retrospective utilization and prior authorization decisions to understand their impacts on access to medically necessary care and financial repercussions for healthcare providers.

• Payment Rules: If a retrospective review or prior authorization results in an adverse determination (meaning the care is deemed unnecessary or inappropriate), health carriers may refuse payment. Providers cannot charge the enrollee or their guarantor for such services.

• Termination Conditions: The program can be terminated early if the commissioner finds significant negative impacts on access to necessary care or increased costs for enrollees. If the program ends, all stakeholders will be notified, and operations will cease the following January.

• Evaluation and Reporting: The commissioner of management and budget, along with the commissioner of health, will evaluate the pilot's effectiveness and prepare annual reports starting March 1, 2027. These reports will include recommendations about the program's continuation or expansion.

Significant Changes to Existing Law

This bill introduces a new approach to health care service evaluations for state employees by piloting retrospective utilization reviews, potentially replacing or supplementing traditional prior authorizations. This could significantly alter how care determinations and payments are processed for state employees.

Relevant Terms

• State employee group insurance program
• Utilization review
• Prior authorization
• Retrospective utilization review
• Medically necessary care
• Health carrier
• Adverse determination