New York State Assembly

 
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A00463 Summary:

A00463 Actions:

A00463 Committee Votes:

Committee:INSURANCE   Chair:Weprin      
DATE:05/17/2023AYE/NAY:24/0  Action: Favorable refer to committee Rules        
Weprin
Aye
Blankenbush
Aye
Cook
Aye
Hawley
Aye
Pretlow
Aye
Palmesano
Aye
Lavine
Aye
Gandolfo
Aye
Steck
Aye
Curran
Aye
Dilan
Aye
Jensen
Aye
Hunter
Aye
Blumencranz
Aye
Rosenthal
Aye
Bendett
Aye
Stern
Aye
Jacobson
Aye
Meeks
Aye
Forrest
Aye
Anderson
Aye
Cruz
Aye
Bores
Aye
Lunsford
Aye

Committee:RULES   Chair:Pretlow      
DATE:06/05/2023AYE/NAY:28/0  Action: Favorable         
Heastie
Excused
Barclay
Aye
Weinstein
Aye
Hawley
Aye
Pretlow
Aye
Giglio
Aye
Cook
Aye
Blankenbush
Excused
Glick
Aye
Norris
Aye
Aubry
Aye
Ra
Aye
Dinowitz
Aye
Brabenec
Aye
Colton
Aye
Palmesano
Aye
Magnarelli
Aye
Reilly
Aye
Paulin
Aye
Peoples-Stokes
Aye
Benedetto
Aye
Lavine
Aye
Lupardo
Aye
Zebrowski
Aye
Thiele
Aye
Braunstein
Aye
Dickens
Aye
Davila
Aye
Hyndman
Excused
Rozic
Aye
Bronson
Aye

A00463 Floor Votes:

A00463 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         463--A
 
                               2023-2024 Regular Sessions
 
                   IN ASSEMBLY
 
                                     January 9, 2023
                                       ___________
 
        Introduced  by  M.  of  A.  McDONALD,  STECK, GUNTHER, STIRPE, K. BROWN,
          WEPRIN, COLTON, BENDETT -- read once and referred to the Committee  on
          Insurance  -- reported and referred to the Committee on Rules -- Rules
          Committee discharged, bill amended, ordered reprinted as  amended  and
          recommitted to the Committee on Rules

        AN ACT to amend the insurance law and the public health law, in relation
          to requiring notice of adverse step therapy determinations
 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section 1. Subsection (a) of section 4902  of  the  insurance  law  is
     2  amended by adding a new paragraph 14 to read as follows:
     3    (14) Establishment of a written procedure to assure that the notice of
     4  an adverse determination in relation to a step therapy protocol override
     5  determination request includes:
     6    (i)  the  reasons for the determination including the clinical ration-
     7  ale, if any;
     8    (ii) instructions on how to initiate standard  and  expedited  appeals
     9  pursuant  to section four thousand nine hundred four of this article and
    10  an external appeal pursuant to section four thousand nine hundred  four-
    11  teen of this article;
    12    (iii)  information  that  includes: any applicable alternative covered
    13  medications; the clinical review  criteria  relied  upon  to  make  such
    14  determination;  and  any  additional  necessary information that must be
    15  provided to, or obtained by, the utilization review agent  in  order  to
    16  render a decision on the appeal;
    17    (iv)  the provisions of this section shall be satisfied by making such
    18  information available electronically on  a  formulary  website,  on  the
    19  member  portal and/or provider portal of the insurer's, the health main-
    20  tenance organization's  website,  or  the  website  of  an  organization
    21  subject to article forty-three of this chapter, provided that the member
    22  consents to receiving the information electronically.
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02500-03-3
        A. 463--A                           2
 
     1    §  2.  Section  4903  of  the insurance law is amended by adding a new
     2  subsection (e-1) to read as follows:
     3    (e-1)  Notice of an adverse determination made by a utilization review
     4  agent in relation to a  step  therapy  protocol  override  determination
     5  request shall be made in writing to the insured or the insured's author-
     6  ized  representative  and  the insured's prescribing health care profes-
     7  sional as defined in subsection (f) of  section  forty-nine  hundred  of
     8  this chapter, and shall include:
     9    (i)  the  reasons for the determination including the clinical ration-
    10  ale, if any;
    11    (ii) instructions on how to initiate standard  and  expedited  appeals
    12  pursuant  to section four thousand nine hundred four of this article and
    13  an external appeal pursuant to section four thousand nine hundred  four-
    14  teen of this article;
    15    (iii)  information  that  includes: any applicable alternative covered
    16  medications; the clinical review  criteria  relied  upon  to  make  such
    17  determination;  and  any  additional  necessary information that must be
    18  provided to, or obtained by, the utilization review agent  in  order  to
    19  render a decision on the appeal;
    20    (iv)  the provisions of this section shall be satisfied by making such
    21  information available electronically on  a  formulary  website,  on  the
    22  member  portal and/or provider portal of the insurer's, the health main-
    23  tenance organization's  website,  or  the  website  of  an  organization
    24  subject to article forty-three of this chapter, provided that the member
    25  consents to receiving the information electronically.
    26    § 3. Subdivision 1 of section 4902 of the public health law is amended
    27  by adding a new paragraph (l) to read as follows:
    28    (l)  Establishment of a written procedure to assure that the notice of
    29  an adverse determination in relation to a step therapy protocol override
    30  determination request includes: (i) the reasons  for  the  determination
    31  including  the  clinical  rationale, if any; (ii) instructions on how to
    32  initiate standard and expedited appeals pursuant to subdivision  two  of
    33  section  forty-nine  hundred  four  of this title and an external appeal
    34  pursuant to section forty-nine hundred fourteen of this  article;  (iii)
    35  information  that  includes:  any applicable alternative covered medica-
    36  tions; the clinical review criteria relied upon to  make  such  determi-
    37  nation;  and  any additional necessary information that must be provided
    38  to, or obtained by, the utilization review agent in order  to  render  a
    39  decision  on  the  appeal;  (iv) the provisions of this section shall be
    40  satisfied by making  such  information  available  electronically  on  a
    41  formulary  website,  on  the member portal and/or provider portal of the
    42  insurer's, the health maintenance organization's website, or the website
    43  of an organization subject  to  article  forty-three  of  this  chapter,
    44  provided that the member consents to receiving the information electron-
    45  ically.
    46    §  4. Section 4903 of the public health law is amended by adding a new
    47  subdivision 5-a to read as follows:
    48    5-a. Notice of an adverse determination made by a  utilization  review
    49  agent  in  relation  to  a  step therapy protocol override determination
    50  request shall be made in writing  to  the  enrollee  or  the  enrollee's
    51  authorized  representative  and  the  enrollee's prescribing health care
    52  professional as defined in subdivision six of section forty-nine hundred
    53  of this title, and shall include:
    54    (a) the reasons for the determination including the  clinical  ration-
    55  ale, if any;
        A. 463--A                           3
 
     1    (b)  instructions  on  how  to initiate standard and expedited appeals
     2  pursuant to section  forty-nine  hundred  four  of  this  title  and  an
     3  external  appeal pursuant to section forty-nine hundred fourteen of this
     4  article;
     5    (c)  information  that  includes:  any  applicable alternative covered
     6  medications; the clinical review  criteria  relied  upon  to  make  such
     7  determination;  and  any  additional  necessary information that must be
     8  provided to, or obtained by, the utilization review agent  in  order  to
     9  render a decision on the appeal;
    10    (d)  the  provisions of this section shall be satisfied by making such
    11  information available electronically on  a  formulary  website,  on  the
    12  member  portal and/or provider portal of the insurer's, the health main-
    13  tenance organization's  website,  or  the  website  of  an  organization
    14  subject to article forty-three of this chapter, provided that the member
    15  consents to receiving the information electronically.
    16    §  5.  This  act shall take effect on the ninetieth day after it shall
    17  have become a law. Effective immediately, the addition, amendment and/or
    18  repeal of any rule or regulation necessary  for  the  implementation  of
    19  this  act  on its effective date are authorized to be made and completed
    20  on or before such effective date.