SF 1509

Introduction - 94th Legislature (2025 - 2026)

Posted on 02/18/2025 10:03 a.m.

A bill for an act
relating to human services; requiring medical assistance coverage of drugs covered
by a primary third-party payer; requiring coverage of in-network services by
medical assistance regardless of network or referral status for a primary third-party
payer; amending Minnesota Statutes 2024, sections 256B.0625, subdivisions 13,
25b; 256B.37, subdivision 5.

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

Section 1.

Minnesota Statutes 2024, section 256B.0625, subdivision 13, is amended to
read:

Subd. 13.

Drugs.

(a) Medical assistance covers drugs, except for fertility drugs when
specifically used to enhance fertility, if prescribed by a licensed practitioner and dispensed
by a licensed pharmacist, by a physician enrolled in the medical assistance program as a
dispensing physician, or by a physician, a physician assistant, or an advanced practice
registered nurse employed by or under contract with a community health board as defined
in section 145A.02, subdivision 5, for the purposes of communicable disease control.

(b) The dispensed quantity of a prescription drug must not exceed a 34-day supply unless
authorized by the commissioner or as provided in paragraph (h) or the drug appears on the
90-day supply list published by the commissioner. The 90-day supply list shall be published
by the commissioner on the department's website. The commissioner may add to, delete
from, and otherwise modify the 90-day supply list after providing public notice and the
opportunity for a 15-day public comment period. The 90-day supply list may include
cost-effective generic drugs and shall not include controlled substances.

(c) For the purpose of this subdivision and subdivision 13d, an "active pharmaceutical
ingredient" is defined as a substance that is represented for use in a drug and when used in
the manufacturing, processing, or packaging of a drug becomes an active ingredient of the
drug product. An "excipient" is defined as an inert substance used as a diluent or vehicle
for a drug. The commissioner shall establish a list of active pharmaceutical ingredients and
excipients which are included in the medical assistance formulary. Medical assistance covers
selected active pharmaceutical ingredients and excipients used in compounded prescriptions
when the compounded combination is specifically approved by the commissioner or when
a commercially available product:

(1) is not a therapeutic option for the patient;

(2) does not exist in the same combination of active ingredients in the same strengths
as the compounded prescription; and

(3) cannot be used in place of the active pharmaceutical ingredient in the compounded
prescription.

(d) Medical assistance covers the following over-the-counter drugs when prescribed by
a licensed practitioner or by a licensed pharmacist who meets standards established by the
commissioner, in consultation with the board of pharmacy: antacids, acetaminophen, family
planning products, aspirin, insulin, products for the treatment of lice, vitamins for adults
with documented vitamin deficiencies, vitamins for children under the age of seven and
pregnant or nursing women, and any other over-the-counter drug identified by the
commissioner, in consultation with the Formulary Committee, as necessary, appropriate,
and cost-effective for the treatment of certain specified chronic diseases, conditions, or
disorders, and this determination shall not be subject to the requirements of chapter 14. A
pharmacist may prescribe over-the-counter medications as provided under this paragraph
for purposes of receiving reimbursement under Medicaid. When prescribing over-the-counter
drugs under this paragraph, licensed pharmacists must consult with the recipient to determine
necessity, provide drug counseling, review drug therapy for potential adverse interactions,
and make referrals as needed to other health care professionals.

(e) Effective January 1, 2006, medical assistance shall not cover drugs that are coverable
under Medicare Part D as defined in the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Public Law 108-173, section 1860D-2(e), for individuals eligible
for drug coverage as defined in the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, Public Law 108-173, section 1860D-1(a)(3)(A). For these
individuals, medical assistance may cover drugs from the drug classes listed in United States
Code, title 42, section 1396r-8(d)(2), subject to this subdivision and subdivisions 13a to
13g, except that drugs listed in United States Code, title 42, section 1396r-8(d)(2)(E), shall
not be covered.

(f) Medical assistance covers drugs acquired through the federal 340B Drug Pricing
Program and dispensed by 340B covered entities and ambulatory pharmacies under common
ownership of the 340B covered entity. Medical assistance does not cover drugs acquired
through the federal 340B Drug Pricing Program and dispensed by 340B contract pharmacies.

(g) Notwithstanding paragraph (a), medical assistance covers self-administered hormonal
contraceptives prescribed and dispensed by a licensed pharmacist in accordance with section
151.37, subdivision 14; nicotine replacement medications prescribed and dispensed by a
licensed pharmacist in accordance with section 151.37, subdivision 15; and opiate antagonists
used for the treatment of an acute opiate overdose prescribed and dispensed by a licensed
pharmacist in accordance with section 151.37, subdivision 16.

(h) Medical assistance coverage for a prescription contraceptive must provide a 12-month
supply for any prescription contraceptive if a 12-month supply is prescribed by the
prescribing health care provider. The prescribing health care provider must determine the
appropriate duration for which to prescribe the prescription contraceptives, up to 12 months.
For purposes of this paragraph, "prescription contraceptive" means any drug or device that
requires a prescription and is approved by the Food and Drug Administration to prevent
pregnancy. Prescription contraceptive does not include an emergency contraceptive drug
approved to prevent pregnancy when administered after sexual contact. For purposes of this
paragraph, "health plan" has the meaning provided in section 62Q.01, subdivision 3.

new text begin (i) Notwithstanding subdivisions 13d and 13g, medical assistance covers any drug on
the formulary of the recipient's primary third-party payer for which the primary third-party
payer has made partial payment, regardless of the drug's exclusion from the medical
assistance formulary or preferred drug list. Notwithstanding subdivision 13f, medical
assistance must cover drugs under this paragraph without requiring prior authorization.
Medical assistance must cover drugs under this paragraph regardless of the payment amount
initially covered by the primary third-party payer.
new text end

Sec. 2.

Minnesota Statutes 2024, section 256B.0625, subdivision 25b, is amended to read:

Subd. 25b.

Authorization with third-party liability.

(a) Except as otherwise allowed
under this subdivision or required under federal or state regulations, the commissioner must
not consider a request for authorization of a service when the recipient has coverage from
a third-party payer unless the provider requesting authorization has made a good faith effort
to receive payment or authorization from the third-party payer. A good faith effort is
established by supplying with the authorization request to the commissioner the following:

(1) a determination of payment for the service from the third-party payer, a determination
of authorization for the service from the third-party payer, or a verification of noncoverage
of the service by the third-party payer; and

(2) the information or records required by the department to document the reason for
the determination or to validate noncoverage from the third-party payer.

(b) A provider requesting authorization for services covered by Medicare is not required
to bill Medicare before requesting authorization from the commissioner if the provider has
reason to believe that a service covered by Medicare is not eligible for payment. The provider
must document that, because of recent claim experiences with Medicare or because of
written communication from Medicare, coverage is not available for the service.

(c) Authorization is not required if a third-party payer has made payment that is equal
to or greater than 60 percent of the maximum payment amount for the service allowed under
medical assistance new text begin , except that authorization of drugs covered by a primary third-party payer
is not required regardless of payment amount pursuant to subdivision 13, paragraph (i) new text end .

Sec. 3.

Minnesota Statutes 2024, section 256B.37, subdivision 5, is amended to read:

Subd. 5.

Private benefits to be used first.

new text begin (a) new text end Private accident and health care coverage
including Medicare for medical services is primary coverage and must be exhausted before
medical assistance or alternative care services are paid for medical services including home
health care, personal care assistance services, hospice, supplies and equipment, or services
covered under a Centers for Medicare and Medicaid Services waiver. When a person who
is otherwise eligible for medical assistance has private accident or health care coverage,
including Medicare or a prepaid health plan, the private health care benefits available to the
person must be used first and to the fullest extent.

new text begin (b) Medical assistance must cover medical services a primary third-party payer deems
out-of-network or as requiring referral if the medical services are in-network and do not
require a referral under medical assistance.
new text end