SF3123 (Legislative Session 94 (2025-2026))
State employee group insurance program utilization review pilot program establishment
Related bill: HF2555
AI Generated Summary
Purpose of the Bill
The bill aims to establish a pilot program to evaluate different methods of health care reviews within the Minnesota state employee group insurance program. The goal is to compare the effectiveness, costs, and benefits of retrospective utilization reviews against prior authorizations for medical services and facilities.
Main Provisions
Pilot Program Establishment: The program will run from January 1, 2026, to December 31, 2030. It focuses on using retrospective utilization reviews, allowing health plans to optionally use prior authorizations.
Quality and Payment Audits: Health carriers are required to conduct audits to assess the impact of the program on access to care and payment processes.
Payment Guidelines: If a health service is deemed unnecessary (adverse determination), health carriers may refuse payment. Providers cannot charge patients for services not covered due to such determinations.
Termination Clause: The program can be terminated by the commissioner if it's found to negatively affect access to necessary medical care or significantly increase costs to enrollees or the state.
Reporting Requirements: Annual reports are mandated, starting March 1, 2027, to review the program's impact on costs and care access, and to determine if it should continue or expand.
Significant Changes to Existing Law
The bill introduces a new method of evaluating healthcare services in the state employee insurance program through a pilot program that contrasts retrospective review and prior authorization processes. It shifts focus from pre-service authorization to post-service evaluation, offering an opportunity to potentially alter how healthcare services are managed and paid.
Relevant Terms
- State employee group insurance program
- Utilization review
- Retrospective utilization review
- Prior authorization
- Medically necessary care
- Health carrier
- Health plan
Bill text versions
- Introduction PDF file
Actions
| Date | Chamber | Where | Type | Name | Committee Name |
|---|---|---|---|---|---|
| March 31, 2025 | Senate | Floor | Action | Introduction and first reading | |
| March 31, 2025 | Senate | Floor | Action | Referred to | State and Local Government |
Citations
[
{
"analysis": {
"added": [],
"removed": [],
"summary": "References the operation of nonprofit health service plan corporations under chapter 62C.",
"modified": []
},
"citation": "62C",
"subdivision": ""
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "References the operation of health maintenance organizations under chapter 62D.",
"modified": []
},
"citation": "62D",
"subdivision": ""
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "References the definition of a health plan as given in section 62A.011, subdivision 3.",
"modified": []
},
"citation": "62A.011",
"subdivision": "subdivision 3"
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "References the definition of medically necessary care as given in section 62Q.53, subdivision 2.",
"modified": []
},
"citation": "62Q.53",
"subdivision": "subdivision 2"
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "References the definition of prior authorization as given in section 62M.02, subdivision 15.",
"modified": []
},
"citation": "62M.02",
"subdivision": "subdivision 15"
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "References the state employee group insurance program under sections 43A.22 to 43A.31.",
"modified": []
},
"citation": "43A.22 to 43A.31",
"subdivision": ""
},
{
"analysis": {
"added": [],
"removed": [],
"summary": "References the requirements and timelines for utilization review as given in chapter 62M.",
"modified": []
},
"citation": "62M",
"subdivision": ""
}
]