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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 modify current laws related to healthcare services in Minnesota. It focuses on how changes in clinical criteria and utilization review should be applied, particularly concerning prior authorization processes for healthcare services.

Main Provisions

  • Prior Authorization Changes: The bill outlines that any changes in coverage terms or clinical criteria for healthcare services cannot be applied within the same plan or calendar year once prior authorization has been granted under the terms previously in place. This means enrollees are protected from mid-year changes.

  • Exceptions to the Rule: There are specific scenarios where changes can be implemented immediately:

    • If a drug or medical device is deemed unsafe or withdrawn by the FDA or the manufacturer.
    • If independent research or clinical guidelines suggest modifications due to patient harm.
    • Changes required due to previously unknown, imminent patient risks.

  • Drug Formulary Adjustments: If a brand name drug is removed from a formulary or placed into a higher cost category, the organization must:

    • Add a lower-cost therapeutic equivalent to the formulary.
    • Provide a 60-day notice to all stakeholders, including prescribers, pharmacists, and affected enrollees.

  • Future Implementation Date: Some changes outlined will only take effect on or after January 1, 2026.

Significant Changes to Existing Law

  • Delayed Application of Changes: This bill mandates that changes to clinical criteria or coverage terms related to prior authorizations are delayed until the following year unless certain safety or research-based exceptions apply.

  • Utilization Review Provisions: Additional provisions from Minnesota's chapter 62M will be applied to services under chapters 256B and 256L by January 1, 2026, which means more rigorous standards and practices will be enforced for managing healthcare services and costs.

Relevant Terms

  • Prior Authorization
  • Utilization Review
  • Clinical Criteria
  • FDA Safety Withdrawals
  • Therapeutically Equivalent
  • Formulary Changes

Bill text versions

Actions

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

Citations

 
[
  {
    "analysis": {
      "added": [
        "Clarifies applicability of changes during a plan or calendar year."
      ],
      "removed": [],
      "summary": "This section relates to the effect of changes in prior authorization clinical criteria for health care services.",
      "modified": [
        "Specifies conditions under which prior authorization terms do not apply after changes are made."
      ]
    },
    "citation": "62M.17"
  },
  {
    "analysis": {
      "added": [
        "Introduces effective dates for applicability of certain chapter 62M provisions to the commissioner."
      ],
      "removed": [],
      "summary": "This section pertains to the applicability of utilization review provisions in delivering services.",
      "modified": [
        "Specifies the scope and conditions under which certain utilization review provisions apply."
      ]
    },
    "citation": "256B.0625"
  }
]

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