1.1                          A bill for an act 
  1.2             relating to health care; expanding medical assistance 
  1.3             coverage to include tuberculosis related services; 
  1.4             amending Minnesota Statutes 1994, section 256B.0625, 
  1.5             subdivision 13, and by adding a subdivision. 
  1.6   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.7      Section 1.  Minnesota Statutes 1994, section 256B.0625, 
  1.8   subdivision 13, is amended to read: 
  1.9      Subd. 13.  [DRUGS.] (a) Medical assistance covers drugs if 
  1.10  prescribed by a licensed practitioner and dispensed by a 
  1.11  licensed pharmacist, ~~or~~ by a physician enrolled in the medical 
  1.12  assistance program as a dispensing physician, or by a physician 
  1.13  or a nurse practitioner employed by or under contract with a 
  1.14  community health board as defined in section 145A.02, 
  1.15  subdivision 5, for the purposes of communicable disease 
  1.16  control.  The commissioner, after receiving recommendations from 
  1.17  professional medical associations and professional pharmacist 
  1.18  associations, shall designate a formulary committee to advise 
  1.19  the commissioner on the names of drugs for which payment is 
  1.20  made, recommend a system for reimbursing providers on a set fee 
  1.21  or charge basis rather than the present system, and develop 
  1.22  methods encouraging use of generic drugs when they are less 
  1.23  expensive and equally effective as trademark drugs.  The 
  1.24  formulary committee shall consist of nine members, four of whom 
  1.25  shall be physicians who are not employed by the department of 
  2.1   human services, and a majority of whose practice is for persons 
  2.2   paying privately or through health insurance, three of whom 
  2.3   shall be pharmacists who are not employed by the department of 
  2.4   human services, and a majority of whose practice is for persons 
  2.5   paying privately or through health insurance, a consumer 
  2.6   representative, and a nursing home representative.  Committee 
  2.7   members shall serve three-year terms and shall serve without 
  2.8   compensation.  Members may be reappointed once.  
  2.9      (b) The commissioner shall establish a drug formulary.  Its 
  2.10  establishment and publication shall not be subject to the 
  2.11  requirements of the administrative procedure act, but the 
  2.12  formulary committee shall review and comment on the formulary 
  2.13  contents.  The formulary committee shall review and recommend 
  2.14  drugs which require prior authorization.  The formulary 
  2.15  committee may recommend drugs for prior authorization directly 
  2.16  to the commissioner, as long as opportunity for public input is 
  2.17  provided.  Prior authorization may be requested by the 
  2.18  commissioner based on medical and clinical criteria before 
  2.19  certain drugs are eligible for payment.  Before a drug may be 
  2.20  considered for prior authorization at the request of the 
  2.21  commissioner:  
  2.22     (1) the drug formulary committee must develop criteria to 
  2.23  be used for identifying drugs; the development of these criteria 
  2.24  is not subject to the requirements of chapter 14, but the 
  2.25  formulary committee shall provide opportunity for public input 
  2.26  in developing criteria; 
  2.27     (2) the drug formulary committee must hold a public forum 
  2.28  and receive public comment for an additional 15 days; and 
  2.29     (3) the commissioner must provide information to the 
  2.30  formulary committee on the impact that placing the drug on prior 
  2.31  authorization will have on the quality of patient care and 
  2.32  information regarding whether the drug is subject to clinical 
  2.33  abuse or misuse.  Prior authorization may be required by the 
  2.34  commissioner before certain formulary drugs are eligible for 
  2.35  payment.  The formulary shall not include:  
  2.36     (i) drugs or products for which there is no federal 
  3.1   funding; 
  3.2      (ii) over-the-counter drugs, except for antacids, 
  3.3   acetaminophen, family planning products, aspirin, insulin, 
  3.4   products for the treatment of lice, vitamins for adults with 
  3.5   documented vitamin deficiencies, and vitamins for children under 
  3.6   the age of seven and pregnant or nursing women; 
  3.7      (iii) any other over-the-counter drug identified by the 
  3.8   commissioner, in consultation with the drug formulary committee, 
  3.9   as necessary, appropriate, and cost-effective for the treatment 
  3.10  of certain specified chronic diseases, conditions or disorders, 
  3.11  and this determination shall not be subject to the requirements 
  3.12  of chapter 14; 
  3.13     (iv) anorectics; and 
  3.14     (v) drugs for which medical value has not been established. 
  3.15     The commissioner shall publish conditions for prohibiting 
  3.16  payment for specific drugs after considering the formulary 
  3.17  committee's recommendations.  
  3.18     (c) The basis for determining the amount of payment shall 
  3.19  be the lower of the actual acquisition costs of the drugs plus a 
  3.20  fixed dispensing fee established by the commissioner, the 
  3.21  maximum allowable cost set by the federal government or by the 
  3.22  commissioner plus the fixed dispensing fee or the usual and 
  3.23  customary price charged to the public.  Actual acquisition cost 
  3.24  includes quantity and other special discounts except time and 
  3.25  cash discounts.  The actual acquisition cost of a drug shall be 
  3.26  estimated by the commissioner, at average wholesale price minus 
  3.27  7.6 percent effective January 1, 1994.  The maximum allowable 
  3.28  cost of a multisource drug may be set by the commissioner and it 
  3.29  shall be comparable to, but no higher than, the maximum amount 
  3.30  paid by other third-party payors in this state who have maximum 
  3.31  allowable cost programs.  Establishment of the amount of payment 
  3.32  for drugs shall not be subject to the requirements of the 
  3.33  administrative procedure act.  An additional dispensing fee of 
  3.34  $.30 may be added to the dispensing fee paid to pharmacists for 
  3.35  legend drug prescriptions dispensed to residents of long-term 
  3.36  care facilities when a unit dose blister card system, approved 
  4.1   by the department, is used.  Under this type of dispensing 
  4.2   system, the pharmacist must dispense a 30-day supply of drug.  
  4.3   The National Drug Code (NDC) from the drug container used to 
  4.4   fill the blister card must be identified on the claim to the 
  4.5   department.  The unit dose blister card containing the drug must 
  4.6   meet the packaging standards set forth in Minnesota Rules, part 
  4.7   6800.2700, that govern the return of unused drugs to the 
  4.8   pharmacy for reuse.  The pharmacy provider will be required to 
  4.9   credit the department for the actual acquisition cost of all 
  4.10  unused drugs that are eligible for reuse.  Over-the-counter 
  4.11  medications must be dispensed in the manufacturer's unopened 
  4.12  package.  The commissioner may permit the drug clozapine to be 
  4.13  dispensed in a quantity that is less than a 30-day supply.  
  4.14  Whenever a generically equivalent product is available, payment 
  4.15  shall be on the basis of the actual acquisition cost of the 
  4.16  generic drug, unless the prescriber specifically indicates 
  4.17  "dispense as written - brand necessary" on the prescription as 
  4.18  required by section 151.21, subdivision 2.  Implementation of 
  4.19  any change in the fixed dispensing fee that has not been subject 
  4.20  to the administrative procedure act is limited to not more than 
  4.21  180 days, unless, during that time, the commissioner initiates 
  4.22  rulemaking through the administrative procedure act. 
  4.23     (d) Until the date the on-line, real-time Medicaid 
  4.24  Management Information System (MMIS) upgrade is successfully 
  4.25  implemented, as determined by the commissioner of 
  4.26  administration, a pharmacy provider may require individuals who 
  4.27  seek to become eligible for medical assistance under a one-month 
  4.28  spenddown, as provided in section 256B.056, subdivision 5, to 
  4.29  pay for services to the extent of the spenddown amount at the 
  4.30  time the services are provided.  A pharmacy provider choosing 
  4.31  this option shall file a medical assistance claim for the 
  4.32  pharmacy services provided.  If medical assistance reimbursement 
  4.33  is received for this claim, the pharmacy provider shall return 
  4.34  to the individual the total amount paid by the individual for 
  4.35  the pharmacy services reimbursed by the medical assistance 
  4.36  program.  If the claim is not eligible for medical assistance 
  5.1   reimbursement because of the provider's failure to comply with 
  5.2   the provisions of the medical assistance program, the pharmacy 
  5.3   provider shall refund to the individual the total amount paid by 
  5.4   the individual.  Pharmacy providers may choose this option only 
  5.5   if they apply similar credit restrictions to private pay or 
  5.6   privately insured individuals.  A pharmacy provider choosing 
  5.7   this option must inform individuals who seek to become eligible 
  5.8   for medical assistance under a one-month spenddown of (1) their 
  5.9   right to appeal the denial of services on the grounds that they 
  5.10  have satisfied the spenddown requirement, and (2) their 
  5.11  potential eligibility for the MinnesotaCare program or the 
  5.12  children's health plan. 
  5.13     Sec. 2.  Minnesota Statutes 1994, section 256B.0625, is 
  5.14  amended by adding a subdivision to read: 
  5.15     Subd. 38.  [TUBERCULOSIS RELATED SERVICES.] (a) For persons 
  5.16  infected with tuberculosis, medical assistance covers case 
  5.17  management services and direct observation of the intake of 
  5.18  drugs prescribed to treat tuberculosis. 
  5.19     (b) "Case management services" means services furnished to 
  5.20  assist persons infected with tuberculosis in gaining access to 
  5.21  needed medical services.  Case management services include at a 
  5.22  minimum: 
  5.23     (1) assessing a person's need for medical services to treat 
  5.24  tuberculosis; 
  5.25     (2) developing a care plan that addresses the needs 
  5.26  identified in clause (1); 
  5.27     (3) assisting the person in accessing medical services 
  5.28  identified in the care plan; and 
  5.29     (4) monitoring the person's compliance with the care plan 
  5.30  to ensure completion of tuberculosis therapy.  Medical 
  5.31  assistance covers case management services under this 
  5.32  subdivision only if the services are provided by a certified 
  5.33  public health nurse who is employed by a community health board 
  5.34  as defined in section 145A.02, subdivision 5. 
  5.35     (c) To be covered by medical assistance, tuberculosis drugs 
  5.36  must be dispensed by a licensed pharmacist, physician, or nurse 
  6.1   practitioner who is employed by or under contract with a 
  6.2   community health board as defined in section 145A.02, 
  6.3   subdivision 5.  
  6.4      (d) To be covered by medical assistance, direct observation 
  6.5   of the intake of drugs prescribed to treat tuberculosis must be 
  6.6   provided by a community outreach worker, licensed practical 
  6.7   nurse, registered nurse who is trained and supervised by a 
  6.8   public health nurse employed by a community health board as 
  6.9   defined in section 145A.02, subdivision 5, or a public health 
  6.10  nurse employed by a community health board.