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SF2607 (Legislative Session 94 (2025-2026))

Applicability of prior authorization clinical criteria changes and utilization review provisions modification

Related bill: HF2482

AI Generated Summary

Purpose of the Bill

The bill aims to amend existing Minnesota statutes relating to human services, specifically affecting the applicability of prior authorization clinical criteria changes and utilization review provisions. These changes primarily concern health care plans and how they handle alterations in coverage terms for services and medications.

Main Provisions

  • Delayed Implementation of Changes:

    • For any enrollee who has already received prior authorization for a health care service, any changes in coverage terms or clinical criteria by a utilization review organization shall not take effect until the next plan year or calendar year.

  • Exceptions to Delayed Changes:

    • If a drug or device is deemed unsafe or withdrawn by the FDA or the manufacturer or an independent source issues warnings, the changes to coverage terms will not be delayed.
    • Changes are immediate if independent clinical guidelines recommend usage changes due to patient harm. However, this exception initially covers until December 31, 2025, and slightly changes after that date.

  • Changes Effective January 1, 2026:

    • The bill specifies further conditions post-2025 for when immediate changes can be implemented, such as cases of previously unknown and imminent patient harm.

  • Formulary Changes for Drugs:

    • Utilization review organizations can immediately change coverage terms by removing brand-name drugs from formularies or increasing enrollees' costs if generics or therapeutically equivalent alternatives are provided at a lower cost, accompanied by a 60-day notice to stakeholders.

Significant Changes to Existing Law

  • Introduces new guidelines for how and when utilization review organizations can adjust coverage terms.
  • Specifies the inclusion of new provisions from Minnesota Statutes chapter 62M into existing service delivery frameworks effective January 1, 2026.

Relevant Terms

  • Prior Authorization
  • Clinical Criteria
  • Utilization Review Organizations
  • FDA (Food and Drug Administration)
  • Formulary
  • Therapeutically Equivalent Drugs
  • Imminent Patient Harm

Bill text versions

Actions

DateChamberWhereTypeNameCommittee Name
March 17, 2025SenateFloorActionIntroduction and first reading
March 17, 2025SenateFloorActionReferred toHealth and Human Services

Citations

 
[
  {
    "analysis": {
      "added": [
        "Outlines exceptions to the applicability of paragraph a when independent research recommends changes for safety or when a drug is removed for safety reasons."
      ],
      "removed": [],
      "summary": "The bill amends section 62M.17 regarding the effect of changes in prior authorization clinical criteria in health care services.",
      "modified": [
        "Changes the applicability timelines for alterations in coverage terms to the next plan year or calendar year."
      ]
    },
    "citation": "62M.17",
    "subdivision": "subdivision 2"
  },
  {
    "analysis": {
      "added": [
        "Incorporates several subdivisions of chapter 62M to be effective January 1, 2026, for the delivery of services under chapters 256B and 256L."
      ],
      "removed": [],
      "summary": "This section modifies the applicability of utilization review provisions under chapter 62M to services delivered by the commissioner.",
      "modified": []
    },
    "citation": "256B.0625",
    "subdivision": "subdivision 25c"
  }
]

Progress through the legislative process

17%
In Committee

Sponsors