HF 747

as introduced - 90th Legislature (2017 - 2018) Posted on 04/18/2017 01:33pm

A bill for an act
relating to health care coverage; modifying prior authorization requirements for
prescription drug coverage; requiring prescription drug benefit transparency and
disclosure; amending Minnesota Statutes 2016, sections 62M.07; 256B.69,
subdivision 6; proposing coding for new law in Minnesota Statutes, chapter 62Q.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

Minnesota Statutes 2016, section 62M.07, is amended to read:

62M.07 PRIOR AUTHORIZATION OF SERVICES.

(a) Utilization review organizations conducting prior authorization of services must have
written standards that meet at a minimum the following requirements:

(1) written procedures and criteria used to determine whether care is appropriate,
reasonable, or medically necessary;

(2) a system for providing prompt notification of its determinations to enrollees and
providers and for notifying the provider, enrollee, or enrollee's designee of appeal procedures
under clause (4);

(3) compliance with section 62M.05, subdivisions 3a and 3b, regarding time frames for
approving and disapproving prior authorization requests;

(4) written procedures for appeals of denials of prior authorization which specify the
responsibilities of the enrollee and provider, and which meet the requirements of sections
62M.06 and 72A.285, regarding release of summary review findings; and

(5) procedures to ensure confidentiality of patient-specific information, consistent with
applicable law.

(b) No utilization review organization, health plan company, or claims administrator
may conduct or require prior authorization of emergency confinement or emergency
treatment. The enrollee or the enrollee's authorized representative may be required to notify
the health plan company, claims administrator, or utilization review organization as soon
after the beginning of the emergency confinement or emergency treatment as reasonably
possible.

(c) If prior authorization for a health care service is required, the utilization review
organization, health plan company, or claim administrator must allow providers to submit
requests for prior authorization of the health care services without unreasonable delay by
telephone, facsimile, or voice mail or through an electronic mechanism 24 hours a day,
seven days a week. This paragraph does not apply to dental service covered under
MinnesotaCare or medical assistance.

new text begin (d) Any prior authorization for a prescription drug must remain valid for the duration
of an enrollee's contract term, except that for the benefits offered under section 256B.69 or
chapter 256L, the prior authorization must remain valid for the duration of the enrollee's
enrollment or one year, whichever is shorter. These requirements related to the validity of
prior authorization apply only if:
new text end

new text begin (1) the drug continues to be prescribed for a patient with a condition that requires ongoing
medication therapy;
new text end

new text begin (2) the drug has not otherwise been deemed unsafe by the Food and Drug Administration;
new text end

new text begin (3) the drug has not been withdrawn by the manufacturer or the Food and Drug
Administration;
new text end

new text begin (4) there is no evidence of the enrollee's abuse or misuse of the prescription drug; and
new text end

new text begin (5) no independent source of research, clinical guidelines, or evidence-based standards
has issued drug-specific warnings or recommended changes in drug usage.
new text end

new text begin This paragraph does not apply to individuals assigned to the restricted recipient program
under Minnesota Rules, parts 9505.2160 to 9505.2245.
new text end

Sec. 2.

new text begin [62Q.83] PRESCRIPTION DRUG BENEFIT TRANSPARENCY AND
MANAGEMENT.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For purposes of this section, the following terms have
the meaning given them.
new text end

new text begin (b) "Drug" has the meaning given in section 151.01, subdivision 5.
new text end

new text begin (c) "Enrollee contract year" means the 12-month term during which benefits associated
with health plan company products are in effect. For managed care plans and county-based
purchasing plans under section 256B.69 and chapter 256L, it means a calendar year beginning
January through December.
new text end

new text begin (d) "Formulary" means a list of prescription drugs that have been developed by clinical
and pharmacy experts and represents the health plan company's medically appropriate and
cost-effective prescription drugs approved for use.
new text end

new text begin (e) "Health plan company" has the meaning given in section 62Q.01, subdivision 4, and
includes an entity that performs pharmacy benefits management for the health plan company.
For purposes of this definition, "pharmacy benefits management" means the administration
or management of prescription drug benefits provided by the health plan company for the
benefit of its enrollees and may include, but is not limited to, procurement of prescription
drugs, clinical formulary development and management services, claims processing, and
rebate contracting and administration.
new text end

new text begin (f) "Prescription" has the meaning given in section 151.01, subdivision 16a.
new text end

new text begin Subd. 2. new text end

new text begin Prescription drug benefit disclosure. new text end

new text begin (a) A health plan company that provides
prescription drug benefit coverage and uses a formulary must make its formulary and related
benefit information available by electronic means and, upon request, in writing, at least 30
days prior to annual renewal dates.
new text end

new text begin (b) Formularies must be organized and disclosed consistent with the most recent version
of the United States Pharmacopeia's (USP) Model Guidelines.
new text end

new text begin (c) For each item or category of items on the formulary, the specific enrollee benefit
terms must be identified, including enrollee cost-sharing and expected out-of-pocket costs.
new text end

new text begin Subd. 3. new text end

new text begin Formulary changes. new text end

new text begin (a) Once a formulary has been established, a health plan
company may, at any time during the enrollee's contract year:
new text end

new text begin (1) expand its formulary by adding drugs to the formulary;
new text end

new text begin (2) reduce co-payments or coinsurance; or
new text end

new text begin (3) move a drug to a benefit category that reduces an enrollee's cost.
new text end

new text begin (b) A health plan company may remove a brand name drug from its formulary or place
a brand name drug in a benefit category that increases an enrollee's cost only upon the
addition to the formulary of a generic or multisource brand name drug rated as therapeutically
equivalent according to the FDA Orange Book or a biologic drug rated as interchangeable
according to the FDA Purple Book at a lower cost to the enrollee, and upon at least a 60-day
notice to prescribers, pharmacists, and affected enrollees.
new text end

new text begin (c) A health plan company may change utilization review requirements or move drugs
to a benefit category that increases an enrollee's cost during the enrollee's contract year upon
at least a 60-day notice to prescribers, pharmacists, and affected enrollees, provided that
these changes do not apply to enrollees who are currently taking the drugs affected by these
changes for the duration of the enrollee's contract year.
new text end

new text begin (d) A health plan company may remove any drugs from its formulary that have been
deemed unsafe by the Food and Drug Administration, that have been withdrawn by either
the Food and Drug Administration or the product manufacturer, or when an independent
source of research, clinical guidelines, or evidence-based standards has issued drug-specific
warnings or recommended changes in drug usage.
new text end

Sec. 3.

Minnesota Statutes 2016, section 256B.69, subdivision 6, is amended to read:

Subd. 6.

Service delivery.

(a) Each demonstration provider shall be responsible for the
health care coordination for eligible individuals. Demonstration providers:

(1) shall authorize and arrange for the provision of all needed health services including
but not limited to the full range of services listed in sections 256B.02, subdivision 8, and
256B.0625 in order to ensure appropriate health care is delivered to enrollees.
Notwithstanding section 256B.0621, demonstration providers that provide nursing home
and community-based services under this section shall provide relocation service coordination
to enrolled persons age 65 and over;

(2) shall accept the prospective, per capita payment from the commissioner in return for
the provision of comprehensive and coordinated health care services for eligible individuals
enrolled in the program;

(3) may contract with other health care and social service practitioners to provide services
to enrollees; and

(4) shall institute recipient grievance procedures according to the method established
by the project, utilizing applicable requirements of chapter 62D. Disputes not resolved
through this process shall be appealable to the commissioner as provided in subdivision 11.

(b) Demonstration providers must comply with the standards for claims settlement under
section 72A.201, subdivisions 4, 5, 7, and 8, when contracting with other health care and
social service practitioners to provide services to enrollees. A demonstration provider must
pay a clean claim, as defined in Code of Federal Regulations, title 42, section 447.45(b),
within 30 business days of the date of acceptance of the claim.

new text begin (c) Managed care plans and county-based purchasing plans must comply with chapter
62M and section 62Q.83.
new text end