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SF1509 (Legislative Session 94 (2025-2026))

Medical assistance coverage requirement of drugs covered by a primary third-party payer

Related bill: HF668

AI Generated Summary

The legislative bill S.F. No. 1509 aims to modify existing healthcare laws in Minnesota in several key ways:

  1. Medical Assistance Drug Coverage: The bill mandates that Medical Assistance (MA) must cover prescription drugs, including some over-the-counter medications, as long as they are prescribed by authorized healthcare providers. This coverage extends to drugs that are necessary for managing certain chronic diseases or conditions, as defined by the state.

  2. Long-Term Drug Supplies: For certain prescribed drugs, a supply of up to 90 days can be dispensed, based on a list that the commissioner will maintain and update publicly.

  3. Special Provisions for Specific Medications: The bill specifies coverage for self-administered hormonal contraceptives, nicotine replacement medications, and opiate antagonists, all of which can be prescribed and dispensed by licensed pharmacists. Additionally, it mandates that a 12-month supply of contraceptives can be provided if prescribed by a healthcare provider.

  4. Primary Payer Regulations: If a drug is partially paid for by a primary third-party payer (like private health insurance), MA must cover the remaining cost without requiring prior authorization, regardless of whether the drug is generally covered under the MA formulary.

  5. Service Authorization with Third-Party Liability: Healthcare providers must attempt to obtain payment or authorization from third-party payers before seeking authorization from MA, with certain exceptions detailed regarding the extent of third-party payments already received.

  6. Utilizing Private Benefits First: The bill reiterates that private health insurance, including Medicare, must be utilized before MA or alternative care services are paid, ensuring that MA acts as a payer of last resort when other healthcare coverage exists.

This bill essentially seeks to streamline and expand access to necessary medications and healthcare services for individuals on Medical Assistance in Minnesota, ensuring they receive timely and adequate care regardless of their insurance mix or the specifics of third-party payer coverage agreements.

Bill text versions

Actions

DateChamberWhereTypeNameCommittee Name
February 16, 2025SenateFloorActionIntroduction and first reading
February 16, 2025SenateFloorActionReferred toHealth and Human Services

Citations

 
[
  {
    "analysis": {
      "added": [
        "New provisions for coverage of drugs by pharmacists and conditions for compounded prescriptions.",
        "Coverage for over-the-counter drugs under certain conditions."
      ],
      "removed": [],
      "summary": "This bill amends section 256B.0625, which pertains to medical assistance coverage for drugs.",
      "modified": [
        "Clarifies medical assistance responsibilities for drugs covered under Medicare Part D.",
        "Adjustments to the 90-day supply list management."
      ]
    },
    "citation": "256B.0625"
  },
  {
    "analysis": {
      "added": [
        "Clarification that medical assistance will cover services deemed out-of-network by a third-party if they are in-network under medical assistance."
      ],
      "removed": [],
      "summary": "Amendment to section 256B.37 clarifying the order of benefit usage for medical assistance.",
      "modified": []
    },
    "citation": "256B.37"
  }
]

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