SF 2165

as introduced - 92nd Legislature (2021 - 2022) Posted on 03/19/2021 08:11am

A bill for an act
relating to health care; clarifying the prepaid health plan appeals process; amending
Minnesota Statutes 2020, sections 256.045, subdivision 3a; 256B.0625, subdivisions
13f, 25; 256B.69, by adding a subdivision.

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

Section 1.

Minnesota Statutes 2020, section 256.045, subdivision 3a, is amended to read:

Subd. 3a.

Prepaid health plan appeals.

(a) All prepaid health plans new text begin including managed
care plans and county-based purchasing plans new text end under contract to the commissioner under
chapter 256B must provide for a complaint system according to deleted text begin section 62D.11 deleted text end new text begin federal
regulations and this section new text end . When a prepaid health plan denies, reduces, or terminates a
health service or denies a request to authorize a new text begin health service or new text end previously authorized
health service, the prepaid health plan must notify the recipient of the right to file a complaint
or an appeal new text begin and the recipient's right to request a hearing under paragraph (c) new text end . The notice
must include the name and telephone number of the ombudsman deleted text begin and notice of the recipient's
right to request a hearing under paragraph (b) deleted text end . Recipients may request the assistance of the
ombudsman in the complaint system process. The prepaid health plan must issue a written
resolution of the complaint to the recipient within 30 days after the complaint is filed with
the prepaid health plan. A recipient is required to exhaust the complaint system procedures
in order to request a hearing under paragraph deleted text begin (b) deleted text end new text begin (c) new text end .

(b) new text begin If the resolution of the complaint is adverse to the recipient, the prepaid health plan
must provide the recipient with:
new text end

new text begin (1) the reasons for the adverse determination, including the right of the recipient upon
request and free of charge to reasonable access and copies of all documents, records, and
other information relevant to the adverse determination including all medical necessity
criteria and any processes, strategies, or evidentiary standards used to set coverage limits;
new text end

new text begin (2) the qualifications of the reviewer of the complaint, including any license, certification,
or speciality designation held by the reviewer; and
new text end

new text begin (3) the procedures for filing an appeal of the determination and for requesting a hearing
under paragraph (c).
new text end

new text begin (c) new text end Recipients enrolled in a prepaid health plan under chapter 256B may contest a prepaid
health plan's denial, reduction, or termination of health services, a prepaid health plan's
denial of a request to authorize a previously authorized health service, or the prepaid health
plan's written resolution of a complaint by submitting a written request for a hearing
according to subdivision 3. A state human services judge shall conduct a hearing on the
matter and shall recommend an order to the commissioner of human services. The
commissioner need not grant a hearing if the sole issue raised by a recipient is the
commissioner's authority to require mandatory enrollment in a prepaid health plan in a
county where prepaid health plans are under contract with the commissioner. The state
human services judge may order a second medical opinion from a nonprepaid health plan
provider at the expense of the Department of Human Services. Recipients may request the
assistance of the ombudsman in the appeal process.

deleted text begin (c) deleted text end new text begin (d) new text end In the written request for a hearing to appeal from a prepaid health plan's denial,
reduction, or termination of a health service, a prepaid health plan's denial of a request to
authorize a previously authorized service, or the prepaid health plan's written resolution to
a complaint, a recipient may request an expedited hearing. If an expedited appeal is
warranted, the state human services judge shall hear the appeal and render a decision within
a time commensurate with the level of urgency involved, based on the individual
circumstances of the case.

deleted text begin (d) deleted text end new text begin (e) new text end Beginning January 1, 2018, the requirements of Code of Federal Regulations,
part 42, sections 438.400 to 438.424, take precedence over any conflicting provisions in
this subdivision. All other provisions of this section remain in effect.

Sec. 2.

Minnesota Statutes 2020, section 256B.0625, subdivision 13f, is amended to read:

Subd. 13f.

Prior authorization.

(a) The Formulary Committee shall review and
recommend drugs which require prior authorization. The Formulary Committee shall
establish general criteria to be used for the prior authorization of brand-name drugs for
which generically equivalent drugs are available, but the committee is not required to review
each brand-name drug for which a generically equivalent drug is available.

(b) Prior authorization may be required by the commissioner before certain formulary
drugs are eligible for payment. The Formulary Committee may recommend drugs for prior
authorization directly to the commissioner. The commissioner may also request that the
Formulary Committee review a drug for prior authorization. Before the commissioner may
require prior authorization for a drug:

(1) the commissioner must provide information to the Formulary Committee on the
impact that placing the drug on prior authorization may have on the quality of patient care
and on program costs, information regarding whether the drug is subject to clinical abuse
or misuse, and relevant data from the state Medicaid program if such data is available;

(2) the Formulary Committee must review the drug, taking into account medical and
clinical data and the information provided by the commissioner; and

(3) the Formulary Committee must hold a public forum and receive public comment for
an additional 15 days.

The commissioner must provide a 15-day notice period before implementing the prior
authorization new text begin and may only update prior authorization requirements on an annual basis
unless a drug has been deemed safe by the Food and Drug Administration, has been
withdrawn by the manufacturer or the Food and Drug Administration, or 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 .

(c) Except as provided in subdivision 13j, prior authorization shall not be required or
utilized for any atypical antipsychotic drug prescribed for the treatment of mental illness
if:

(1) there is no generically equivalent drug available; and

(2) the drug was initially prescribed for the recipient prior to July 1, 2003; or

(3) the drug is part of the recipient's current course of treatment.

This paragraph applies to any multistate preferred drug list or supplemental drug rebate
program established or administered by the commissioner. Prior authorization shall
automatically be granted for 60 days for brand name drugs prescribed for treatment of mental
illness within 60 days of when a generically equivalent drug becomes available, provided
that the brand name drug was part of the recipient's course of treatment at the time the
generically equivalent drug became available.

(d) The commissioner may require prior authorization for brand name drugs whenever
a generically equivalent product is available, even if the prescriber specifically indicates
"dispense as written-brand necessary" on the prescription as required by section 151.21,
subdivision 2.

(e) Notwithstanding this subdivision, the commissioner may automatically require prior
authorization, for a period not to exceed 180 days, for any drug that is approved by the
United States Food and Drug Administration on or after July 1, 2005. The 180-day period
begins no later than the first day that a drug is available for shipment to pharmacies within
the state. The Formulary Committee shall recommend to the commissioner general criteria
to be used for the prior authorization of the drugs, but the committee is not required to
review each individual drug. In order to continue prior authorizations for a drug after the
180-day period has expired, the commissioner must follow the provisions of this subdivision.

(f) Prior authorization under this subdivision shall comply with section 62Q.184.

(g) Any step therapy protocol requirements established by the commissioner must comply
with section 62Q.1841.

new text begin (h) If a recipient has received a prior authorization for a drug in accordance with this
subdivision, the prior authorization shall remain valid for the duration of the recipient's
enrollment or one year, whichever is shorter.
new text end

Sec. 3.

Minnesota Statutes 2020, section 256B.0625, subdivision 25, is amended to read:

Subd. 25.

Prior authorization required.

(a) The commissioner shall publish in the
Minnesota health care programs provider manual and on the department's website a list of
health services that require prior authorization, the criteria and standards used to select
health services on the list, and the criteria and standards used to determine whether certain
providers must obtain prior authorization for their services. The list of services requiring
prior authorization and the criteria and standards used to formulate the list of services or
the selection of providers for whom prior authorization is required are not subject to the
requirements of sections 14.001 to 14.69. The commissioner's decision whether prior
authorization is required for a health service or is required for a provider is not subject to
administrative appeal. Use of criteria or standards to select providers for whom prior
authorization is required shall not impede access to the service involved for any group of
individuals with unique or special needs due to disability or functional condition.

(b) The commissioner shall implement a modernized electronic system for providers to
request prior authorization. The modernized electronic system must include at least the
following functionalities:

(1) authorizations are recipient-centric, not provider-centric;

(2) adequate flexibility to support authorizations for an episode of care, continuous drug
therapy, or for individual onetime services and allows an ordering and a rendering provider
to both submit information into one request;

(3) allows providers to review previous authorization requests and determine where a
submitted request is within the authorization process;

(4) supports automated workflows that allow providers to securely submit medical
information that can be accessed by medical and pharmacy review vendors as well as
department staff; and

(5) supports development of automated clinical algorithms that can verify information
and provide responses in real time.

(c) The system described in paragraph (b) shall be completed by March 1, 2012. All
authorization requests submitted on and after March 1, 2012, or upon completion of the
modernized authorization system, whichever is later, must be submitted electronically by
providers, except requests for drugs dispensed by an outpatient pharmacy, services that are
provided outside of the state and surrounding local trade area, and services included on a
service agreement.

new text begin (d) If prior authorization is obtained for a health care service, the prior authorization
must remain valid for the duration of the recipient's enrollment or one year, whichever is
shorter.
new text end

Sec. 4.

Minnesota Statutes 2020, section 256B.69, is amended by adding a subdivision to
read:

new text begin Subd. 11a. new text end

new text begin Prior authorization. new text end

new text begin If a managed care plan or county-based purchasing
plan requires prior authorization of a health care service, the plan must, at a minimum,
provide prompt notification of the plan's prior authorization decision to the enrollee and the
enrollee's provider and notify the enrollee and the enrollee's provider of the right to appeal
the prior authorization decision in accordance with section 256.045, subdivision 3a. If the
plan or the utilization review organization conducting the prior authorization for the plan
needs more information to complete the prior authorization request, the plan or the utilization
review organization must promptly contact the enrollee or the enrollee's provider and specify
the information necessary to complete the prior authorization. The plan or utilization review
organization may deny the prior authorization request if the plan or utilization review
organization notified the enrollee or the enrollee's provider of the necessary information
and the enrollee or the enrollee's provider failed to provide the information within 15 days
of the notification.
new text end