HF 3031

as introduced - 91st Legislature (2019 - 2020) Posted on 02/11/2020 03:37pm

A bill for an act
relating to health care coverage; prohibiting health carriers from limiting or denying
coverage due to a lack of prior authorization; requiring use of a real-time
prescription benefit tool; requiring prescription drug benefit transparency and
disclosure; amending Minnesota Statutes 2018, section 62J.497, subdivisions 1,
3; proposing coding for new law in Minnesota Statutes, chapters 62A; 62Q;
repealing Minnesota Statutes 2018, section 62D.12, subdivision 19.

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

Section 1.

new text begin [62A.605] COVERAGE OF SERVICE; PRIOR AUTHORIZATION.
new text end

new text begin A health carrier may not deny or limit coverage of a service that an enrollee has already
received solely on the basis of lack of prior authorization or second opinion, to the extent
that the service would otherwise have been covered by the health carrier under the enrollee's
health plan had prior authorization or second opinion been obtained.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

Sec. 2.

Minnesota Statutes 2018, section 62J.497, subdivision 1, is amended to read:

Subdivision 1.

Definitions.

(a) For the purposes of this section, the following terms have
the meanings given.

(b) "Backward compatible" means that the newer version of a data transmission standard
would retain, at a minimum, the full functionality of the versions previously adopted, and
would permit the successful completion of the applicable transactions with entities that
continue to use the older versions.

(c) "Dispense" or "dispensing" has the meaning given in section 151.01, subdivision 30.
Dispensing does not include the direct administering of a controlled substance to a patient
by a licensed health care professional.

(d) "Dispenser" means a person authorized by law to dispense a controlled substance,
pursuant to a valid prescription.

(e) "Electronic media" has the meaning given under Code of Federal Regulations, title
45, part 160.103.

(f) "E-prescribing" means the transmission using electronic media of prescription or
prescription-related information between a prescriber, dispenser, pharmacy benefit manager,
or group purchaser, either directly or through an intermediary, including an e-prescribing
network. E-prescribing includes, but is not limited to, two-way transmissions between the
point of care and the dispenser and two-way transmissions related to eligibility, formulary,
and medication history information.

(g) "Electronic prescription drug program" means a program that provides for
e-prescribing.

(h) "Group purchaser" has the meaning given in section 62J.03, subdivision 6.

(i) "HL7 messages" means a standard approved by the standards development
organization known as Health Level Seven.

(j) "National Provider Identifier" or "NPI" means the identifier described under Code
of Federal Regulations, title 45, part 162.406.

(k) "NCPDP" means the National Council for Prescription Drug Programs, Inc.

(l) "NCPDP Formulary and Benefits Standard" means the National Council for
Prescription Drug Programs Formulary and Benefits Standard, Implementation Guide,
Version 1, Release 0, October 2005.

new text begin (m) "NCPDP Real-Time Prescription Benefit Standard" means the most recent National
Council for Prescription Drug Programs Real-Time Prescription Benefit Standard adopted
by the Centers for Medicare and Medicaid Services for e-prescribing under Medicare Part
D as required by section 1860D-4(e)(2) of the Social Security Act, and regulations adopted
under it.
new text end

deleted text begin (m) deleted text end new text begin (n) new text end "NCPDP SCRIPT Standard" means the National Council for Prescription Drug
Programs Prescriber/Pharmacist Interface SCRIPT Standard, Implementation Guide Version
8, Release 1 (Version 8.1), October 2005, or the most recent standard adopted by the Centers
for Medicare and Medicaid Services for e-prescribing under Medicare Part D as required
by section 1860D-4(e)(4)(D) of the Social Security Act, and regulations adopted under it.
The standards shall be implemented according to the Centers for Medicare and Medicaid
Services schedule for compliance. Subsequently released versions of the NCPDP SCRIPT
Standard may be used, provided that the new version of the standard is backward compatible
to the current version adopted by the Centers for Medicare and Medicaid Services.

deleted text begin (n) deleted text end new text begin (o) new text end "Pharmacy" has the meaning given in section 151.01, subdivision 2.

new text begin (p) "Pharmacy benefit manager" has the meaning given in section 62W.02, subdivision
15.
new text end

deleted text begin (o) deleted text end new text begin (q) new text end "Prescriber" means a licensed health care practitioner, other than a veterinarian,
as defined in section 151.01, subdivision 23.

deleted text begin (p) deleted text end new text begin (r) new text end "Prescription-related information" means information regarding eligibility for
drug benefits, medication history, or related health or drug information.

deleted text begin (q) deleted text end new text begin (s) new text end "Provider" or "health care provider" has the meaning given in section 62J.03,
subdivision 8.

new text begin (t) "Real-time prescription benefit tool" means a tool that is capable of being integrated
into a prescriber's e-prescribing system and that provides a prescriber with up-to-date and
patient-specific formulary and benefit information at the time the prescriber submits a
prescription.
new text end

Sec. 3.

Minnesota Statutes 2018, section 62J.497, subdivision 3, is amended to read:

Subd. 3.

Standards for electronic prescribing.

(a) Prescribers and dispensers must use
the NCPDP SCRIPT Standard for the communication of a prescription or prescription-related
information. The NCPDP SCRIPT Standard shall be used to conduct the following
transactions:

(1) get message transaction;

(2) status response transaction;

(3) error response transaction;

(4) new prescription transaction;

(5) prescription change request transaction;

(6) prescription change response transaction;

(7) refill prescription request transaction;

(8) refill prescription response transaction;

(9) verification transaction;

(10) password change transaction;

(11) cancel prescription request transaction; and

(12) cancel prescription response transaction.

(b) Providers, group purchasers, prescribers, and dispensers must use the NCPDP SCRIPT
Standard for communicating and transmitting medication history information.

(c) Providers, group purchasers, prescribers, and dispensers must use the NCPDP
Formulary and Benefits Standard for communicating and transmitting formulary and benefit
information.

(d) Providers, group purchasers, prescribers, and dispensers must use the national provider
identifier to identify a health care provider in e-prescribing or prescription-related transactions
when a health care provider's identifier is required.

(e) Providers, group purchasers, prescribers, and dispensers must communicate eligibility
information and conduct health care eligibility benefit inquiry and response transactions
according to the requirements of section 62J.536.

new text begin (f) Group purchasers and pharmacy benefit managers must use a real-time prescription
benefit tool that complies with the NCPDP Real-Time Prescription Benefit Standard and
that, at a minimum, notifies a prescriber:
new text end

new text begin (1) if a prescribed drug is covered by the patient's group purchaser or pharmacy benefit
manager;
new text end

new text begin (2) if a prescribed drug is included on the formulary or preferred drug list of the patient's
group purchaser or pharmacy benefit manager;
new text end

new text begin (3) any patient cost-sharing for the prescribed drug;
new text end

new text begin (4) if prior authorization is required for the prescribed drug; and
new text end

new text begin (5) a list of any available alternative drugs that are in the same class as the drug originally
prescribed and for which prior authorization is not required.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021.
new text end

Sec. 4.

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 meanings 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 term" 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 single calendar quarter.
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 term:
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 term
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 term.
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 have issued drug-specific
warnings or recommended changes in drug usage.
new text end

Sec. 5. new text begin REPEALER.
new text end

new text begin Minnesota Statutes 2018, section 62D.12, subdivision 19, new text end new text begin is repealed.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2021, and applies to health
plans offered, sold, issued, or renewed on or after that date.
new text end

APPENDIX

Repealed Minnesota Statutes: 20-6046

62D.12 PROHIBITED PRACTICES.

Subd. 19.

Coverage of service.

A health maintenance organization may not deny or limit coverage of a service which the enrollee has already received solely on the basis of lack of prior authorization or second opinion, to the extent that the service would otherwise have been covered under the member's contract by the health maintenance organization had prior authorization or second opinion been obtained.