FOCUS ON NEW LAWS

At the heart of the reforms are measures designed to limit the use of prior authorization, particularly for critical and time-sensitive treatments. The legislation prohibits insurers from requiring prior authorization for non-medication treatments related to cancer care, outpatient mental health services, and substance use disorders. While the law continues to allow prior authorization for medications to treat these conditions, it now requires a decision from the insurer within 48 hours, down from five days. It also prohibits prior authorization for preventive services recommended by the U.S. Preventive Services Task Force, as well as pediatric hospice care and neonatal abstinence programs. One of the most impactful changes is the provision that restricts prior authorization requirements for chronic conditions to one-time approvals. This adjustment is expected to provide continuity of care for patients with ongoing health issues, reducing the administrative burden on both patients and providers.

 
Limits on retroactive coverage denials
The reforms include two key provisions that limit health insurers' ability to deny coverage retroactively. The first provision prohibits health plans from retrospectively denying coverage for services that did not initially require prior authorization. This change aims to prevent situations where patients receive care they believe is covered, only to face denied claims after the fact. Secondly, the law bars insurers from denying coverage solely because a patient lacked prior authorization if the service would have been covered otherwise.
 
Automating and streamlining prior authorization requests
The law also requires health insurers and utilization review organizations to develop an application programming interface (API) that automates prior authorization requests for most health services, excluding prescription drugs. Key features of the API will enable providers to:

• Quickly determine if prior authorization is needed
• Access documentation requirements seamlessly
• Submit requests and receive determinations directly through electronic health records or practice management systems

Annual prior authorization reporting
In a move towards greater transparency, the new law mandates that health plans submit annual reports on their prior authorization practices, including approval and denial rates. This reporting requirement, effective in 2025, will provide valuable data for future policy decisions.
 
Finally, the legislation extends beyond private insurance, applying these reforms to state public programs like Medical Assistance and MinnesotaCare.
 
While the reforms represent a significant step forward, they were not without compromise. The original bill was scaled back due to concerns about the cost to state programs, particularly regarding medication coverage. As Minnesota moves forward with implementation, the impact of these reforms on patient outcomes, provider satisfaction, and overall healthcare costs will become clearer. MNASCA and other provider groups will continue our work to streamline the prior authorization process to promote a more efficient and patient-centered system.
 
MNASCA will be recognizing Representative Kristin Bahner for her leadership in passing these prior authorization reforms at the 2024 MNASCA Annual Conference on October 3.