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HF668 (Legislative Session 94 (2025-2026))

Medical assistance coverage of drugs covered by a primary third-party payer required, and coverage of in-network services by medical assistance regardless of network or referral status for a primary third-party payer required.

Related bill: SF1509

AI Generated Summary

This bill proposes changes to Minnesota's medical assistance program, specifically focusing on drug coverage and the coordination of benefits with primary third-party payers. Here are the main points simplified:

  1. Drug Coverage: Medical assistance will cover medications prescribed and dispensed within the guidelines, including certain over-the-counter drugs if prescribed by a licensed practitioner or pharmacist. There is also mention of a 90-day supply list, which the commissioner will maintain for specific medications that can be supplied for longer periods.

  2. Compounded Prescriptions: Medications that are specially compounded (mixed ingredients to create a specific medication not commercially available) can be covered if there are no commercial alternatives and they meet the approval of the commissioner.

  3. Coordination with Medicare and other Coverage: Medical assistance will not cover drugs that are eligible under Medicare Part D. It will also integrate with other third-party payer systems to ensure drugs partially covered by third-party payers are also covered under medical assistance without requiring further authorization.

  4. Pharmacist's Role: Pharmacists can prescribe certain over-the-counter medications and are expected to provide necessary consultations to ensure the appropriateness of the medication, check for potential interactions, and make referrals if needed.

  5. Primary versus Third-Party Payers:

    • Medical services deemed out-of-network by a primary third-party payer will be covered by medical assistance if they are in-network within the medical assistance framework.
    • Medications partly paid for by third-party payers will be covered without further authorization required, regardless of whether they are on the medical assistance formulary or preferred drug list.

  6. Service Authorization Requirements: Healthcare providers must document efforts to secure payment or authorization from third-party payers before seeking funds from medical assistance. However, certain conditions are provided where prior billing or confirmation from Medicare is not necessary.

  7. Primary Coverage: For recipients with private or other health care coverage, such coverage must be fully utilized before medical assistance payment is issued for related services.

This bill is designed to streamline the coverage process, enhance the coordination between different health insurance systems, and clarify the roles and responsibilities of pharmacists in the medical assistance program.

Bill text versions

Actions

DateChamberWhereTypeNameCommittee Name
February 12, 2025HouseFloorActionIntroduction and first reading, referred toHealth Finance and Policy

Citations

 
[
  {
    "analysis": {
      "added": [
        "Coverage of self-administered hormonal contraceptives, nicotine replacement medications, and opiate antagonists prescribed by pharmacists.",
        "Certain drugs must be covered regardless of exclusion from the formulary if partially covered by a primary third-party payer."
      ],
      "removed": [
        "No changes to existing services were removed."
      ],
      "summary": "The bill amends medical assistance coverage provisions related to drugs and services provided to individuals with third-party insurance coverage.",
      "modified": [
        "Flexibility in dispensed quantities for prescriptions on the 90-day supply list.",
        "Requirements for authorization requests when third-party liability is involved."
      ]
    },
    "citation": "256B.0625"
  },
  {
    "analysis": {
      "added": [
        "Mandate that medical assistance covers services deemed out-of-network by a primary third-party payer, if in-network under medical assistance."
      ],
      "removed": [],
      "summary": "The bill modifies how private health care benefits interact with medical assistance coverage.",
      "modified": [
        "Clarification on the exhaustion requirements of private health coverage before medical assistance payment."
      ]
    },
    "citation": "256B.37"
  }
]

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