HF3869

Purpose

Explain how health insurance prior authorization requirements are changed. The bill aims to reduce or remove the need for prior authorization in certain situations, while still directing how some medical decisions are reviewed and approved.

Key Provisions

• Emergency services and confinement

  • No utilization review organization, health plan company, or claims administrator may require prior authorization for emergency confinement or an emergency service.
  • Enrollees (or their authorized representatives) must notify the plan as soon as reasonably possible after starting the emergency confinement or emergency service.

• Outpatient mental health and substance use disorder treatment (MH/SUD)

  • For outpatient MH/SUD treatment, prior authorizations are not required for the services themselves.
  • For medications used in outpatient MH/SUD treatment, any required prior authorizations must be processed using the established processes for initial determinations (section 62M.05 subdivision 3b) and appeals (section 62M.06 subdivision 2).

• Cancer treatment

  • For antineoplastic (cancer) treatment that is not a medication, prior authorizations are not required.
  • For medications used in antineoplastic cancer treatment, prior authorizations must be processed using the same initial determinations and appeals processes referenced above (62M.05 subdivision 3b for initial determinations and 62M.06 subdivision 2 for appeals).
  • The bill notes that cancer treatment must be consistent with the National Comprehensive Cancer Network (NCCN) guidelines, except for cases that involve medications.

• Exemptions from prior authorization (carved-out services)

  • Services currently rated A or B by the U.S. Preventive Services Task Force (USPSTF) and immunizations recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP).
  • Preventive services and screenings provided to women as described in the specified federal regulation (CFR 45 CFR 147.130).
  • Pediatric hospice services provided by a licensed hospice provider (under Minnesota law).
  • Treatment delivered through a neonatal abstinence program operated by pediatric pain or palliative care subspecialists.
  • Drugs prescribed for and used on an ongoing basis by the enrollee for the immediately preceding six months.

• Effective date and applicability

  • The exemptions (items 4–7 above) take effect January 1, 2026.
  • Applies to health benefit plans offered, sold, issued, or renewed on or after that date.

What this bill changes in practice

• Emergency care access is simplified by removing prior authorization barriers.
• Most non-drug components of outpatient MH/SUD care can proceed without prior authorization; drugs used in MH/SUD care must still go through standard determination and appeal processes.
• Non-drug cancer treatments are not blocked by prior authorizations, but drugs used for cancer treatment must go through standard processes.
• Several key preventive and preventive-related services (immunizations, USPSTF-rated services, ACIP immunizations), plus certain pediatric and neonatal programs and ongoing medications, are protected from prior authorization starting in 2026.
• The changes are targeted and time-delimited to post-2025 plans for the exemptions.

Significance and potential impact

• Expected to reduce administrative delays for emergencies, certain MH/SUD and cancer-related treatments, immunizations, and essential preventive services.
• Could streamline access to care for vulnerable populations (children in hospice or neonatal abstinence program) and for patients on long-term medications.
• Requires health plans to adjust processes to align with the specified exemptions and established determinations/appeals procedures for medications in MH/SUD and cancer care.

Definitions and terminology (key concepts carried in the bill)

• prior authorization / prior authorizations
• emergency confinement
• emergency service
• utilization review organization
• claims administrator
• outpatient mental health treatment
• outpatient substance use disorder treatment
• antineoplastic cancer treatment
• NCCN guidelines
• medications (in cancer and MH/SUD contexts)
• USPSTF (U.S. Preventive Services Task Force)
• ACIP (Advisory Committee on Immunization Practices)
• immunizations
• CFR 45 CFR 147.130
• pediatric hospice services
• neonatal abstinence program
• six months (ongoing medication use)
• initial determinations
• appeals
• health benefit plans

Relevant Terms prior authorization emergency confinement emergency service utilization review organization claims administrator outpatient mental health treatment outpatient substance use disorder treatment antineoplastic cancer treatment NCCN guidelines medications USPSTF ACIP immunizations CFR 45 CFR 147.130 pediatric hospice services neonatal abstinence program ongoing medications initial determinations appeals health benefit plans January 1, 2026