Purpose of the Bill

This bill is designed to modify the rules related to prior authorization and utilization review for healthcare services in Minnesota. It aims to create clear guidelines on when changes to prior authorization requirements can take effect, especially focusing on the timing of these changes and exceptions related to patient safety.

Main Provisions

• Prior Authorization Changes: If a utilization review organization changes the terms or clinical criteria for prior authorizations during a plan year, those changes will not apply to enrollees who have already received prior authorization until the next plan year. This provision is meant to ensure continuity of care and minimize disruptions for patients.

• Exceptions to Delay in Changes:

  • The bill provides exceptions for immediate effect when the U.S. Food and Drug Administration (FDA) or other credible sources identify safety concerns about a drug, device, or service and recommend changes to their usage.
  • For drugs, if a brand name drug is removed from a formulary due to cost changes but replaced with a therapeutically equivalent generic or multisource drug at a lower cost, changes may take effect without delay.

Significant Changes to Existing Law

• The bill mandates that the delay in applying new prior authorization criteria does not apply in specific situations related to drug safety and cost where certain conditions are met.
• Starting January 1, 2026, specific provisions of Minnesota's current utilization review statutes will also apply to services delivered under state healthcare programs (chapters 256B and 256L).

Relevant Terms

• Prior authorization
• Utilization review
• Clinical criteria
• Health care service
• FDA (Food and Drug Administration)
• Formulary
• Therapeutically equivalent
• Evidence-based standards
• Patient safety