SF 3077

as introduced - 91st Legislature (2019 - 2020) Posted on 02/13/2020 03:28pm

A bill for an act
relating to health insurance; specifying limits to prior authorization requirements
for prescription drugs if certain circumstances are met; amending Minnesota Statutes 2018, section 62M.07.

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

Section 1.

Minnesota Statutes 2018, 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) new text begin No utilization review organization, health plan company, claims administrator, or
pharmacy benefit manager may conduct or require prior authorization for a prescribed drug
if:
new text end

new text begin (1) the enrollee has obtained an initial prior authorization from the utilization organization,
health plan company, claims administrator, or pharmacy benefit manager for the prescribed
drug;
new text end

new text begin (2) the enrollee has maintained continuous enrollment in the same health benefit plan
since receiving the initial prior authorization;
new text end

new text begin (3) the enrollee has been prescribed the same drug at the same dosage on a monthly
basis for at least ten consecutive months; and
new text end

new text begin (4) the enrollee's condition that has necessitated the prescribed drug remains stable.
new text end

new text begin Nothing in this paragraph requires a health plan company to provide coverage for a
prescription drug that is not covered under the enrollee's health plan or the health plan's
drug formulary.
new text end

new text begin (d) new text end 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.