Rpld §4902 sub§ (a) ¶14, §4903 sub§ (e-1), amd §§4902 & 4903, Ins L; rpld §4902 sub 1 ¶(1), §4903 sub 5-a,
amd §§4902 & 4903, Pub Health L (as proposed in S.2677-A & A.463-A)
Requires written notice of an adverse determination made by a utilization review agent in relation to a step therapy protocol override determination which includes the clinical review criteria relied upon to make such determination and any applicable alternative prescription drugs subject to the step therapy protocol of the utilization review agent.
STATE OF NEW YORK
________________________________________________________________________
8038
IN SENATE
January 5, 2024
___________
Introduced by Sen. BRESLIN -- read twice and ordered printed, and when
printed to be committed to the Committee on Rules
AN ACT to amend the insurance law and the public health law, in relation
to adverse determinations related to a step therapy protocol override
determination; and to repeal certain provisions of the insurance law
and the public health law relating thereto
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Paragraph 14 of subsection (a) of section 4902 of the
2 insurance law, as added by a chapter of the laws of 2023 amending the
3 insurance law and the public health law relating to requiring notice of
4 adverse step therapy determinations, as proposed in legislative bills
5 numbers S. 2677-A and A. 463-A, is REPEALED.
6 § 2. Paragraph 5 of subsection (a) of section 4902 of the insurance
7 law, as added by chapter 705 of the laws of 1996, subparagraph (ii) as
8 amended by chapter 586 of the laws of 1998, is amended to read as
9 follows:
10 (5) (i) Establishment of a written procedure to assure that the notice
11 of an adverse determination includes:
12 [(i)] (A) the reasons for the determination including the clinical
13 rationale, if any;
14 [(ii)] (B) instructions on how to initiate standard and expedited
15 appeals pursuant to section four thousand nine hundred four of this
16 article and an external appeal pursuant to section four thousand nine
17 hundred fourteen of this article; [and
18 (iii)] (C) notice of the availability, upon request of the insured or
19 the insured's designee, of the clinical review criteria relied upon to
20 make such determination;
21 (D) what, if any, additional necessary information must be provided
22 to, or obtained by, the utilization review agent in order to render a
23 decision on appeal; and
24 (E) for an adverse determination related to a step therapy protocol
25 override determination, information that includes the clinical review
26 criteria relied upon to make such determination and any applicable
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD02500-04-4
S. 8038 2
1 alternative prescription drugs subject to the step therapy protocol of
2 the utilization review agent.
3 (ii) A utilization review agent may provide a notice of an adverse
4 determination related to a step therapy protocol override determination
5 electronically pursuant to subsection (i) of section four thousand nine
6 hundred three of this title, including by electronic mail or through the
7 health care plan's member portal and provider portal. An electronic
8 notice of such an adverse determination may meet the requirements of
9 clause (E) of subparagraph (i) of this paragraph by linking to informa-
10 tion posted on the website of the health care plan;
11 § 3. Subsection (e-1) of section 4903 of the insurance law, as added
12 by a chapter of the laws of 2023 amending the insurance law and the
13 public health law relating to requiring notice of adverse step therapy
14 determinations, as proposed in legislative bills numbers S. 2677-A and
15 A. 463-A, is REPEALED.
16 § 4. Subsection (e) of section 4903 of the insurance law, as added by
17 chapter 705 of the laws of 1996, paragraph 2 as amended by chapter 586
18 of the laws of 1998, is amended to read as follows:
19 (e) (1) Notice of an adverse determination made by a utilization
20 review agent shall be in writing and must include:
21 [(1)] (i) the reasons for the determination including the clinical
22 rationale, if any;
23 [(2)] (ii) instructions on how to initiate standard appeals and expe-
24 dited appeals pursuant to section four thousand nine hundred four and an
25 external appeal pursuant to section four thousand nine hundred fourteen
26 of this article; [and
27 (3)] (iii) notice of the availability, upon request of the insured, or
28 the insured's designee, of the clinical review criteria relied upon to
29 make such determination. Such notice shall also specify what, if any,
30 additional necessary information must be provided to, or obtained by,
31 the utilization review agent in order to render a decision on the
32 appeal; and
33 (iv) for an adverse determination related to a step therapy protocol
34 override request, information that includes the clinical review criteria
35 relied upon to make such determination and any applicable alternative
36 prescription drugs subject to the step therapy protocol of the utiliza-
37 tion review agent.
38 (2) A utilization review agent may provide notice of an adverse deter-
39 mination related to a step therapy protocol override determination elec-
40 tronically pursuant to subsection (i) of this section, including by
41 electronic mail or through the health care plan's member portal and
42 provider portal. An electronic notice of such an adverse determination
43 may meet the requirements of subparagraph (iv) of paragraph one of this
44 subsection by linking to information posted on the website of the health
45 care plan.
46 § 5. Paragraph (l) of subdivision 1 of section 4902 of the public
47 health law, as added by a chapter of the laws of 2023 amending the
48 insurance law and the public health law relating to requiring notice of
49 adverse step therapy determinations, as proposed in legislative bills
50 numbers S. 2677-A and A. 463-A, is REPEALED.
51 § 6. Paragraph (e) of subdivision 1 of section 4902 of the public
52 health law, as added by chapter 705 of the laws of 1996, subparagraph
53 (ii) as amended by chapter 586 of the laws of 1998, is amended to read
54 as follows:
55 (e) (i) Establishment of a written procedure to assure that the notice
56 of an adverse determination includes: [(i)] (1) the reasons for the
S. 8038 3
1 determination including the clinical rationale, if any; [(ii)] (2)
2 instructions on how to initiate standard and expedited appeals pursuant
3 to section forty-nine hundred four and an external appeal pursuant to
4 section forty-nine hundred fourteen of this article; [and (iii)] (3)
5 notice of the availability, upon request of the enrollee or the
6 enrollee's designee, of the clinical review criteria relied upon to make
7 such determination; (4) what, if any, additional necessary information
8 must be provided to, or obtained by, the utilization review agent in
9 order to render a decision on an appeal; and (5) for an adverse determi-
10 nation related to a step therapy protocol override determination, infor-
11 mation that includes the clinical review criteria relied upon to make
12 such determination and any applicable alternative prescription drugs
13 subject to the step therapy protocol of the utilization review agent.
14 (ii) A utilization review agent may provide notice of an adverse
15 determination related to a step therapy protocol override determination
16 electronically pursuant to subdivision nine of section forty-nine
17 hundred three of this title, including by electronic mail or through the
18 health care plan's member portal and provider portal. An electronic
19 notice of such an adverse determination may meet the requirements of
20 clause five of subparagraph (i) of this paragraph by linking to informa-
21 tion posted on the website of the health care plan;
22 § 7. Subdivision 5-a of section 4903 of the public health law, as
23 added by a chapter of the laws of 2023 amending the insurance law and
24 the public health law relating to requiring notice of adverse step ther-
25 apy determinations, as proposed in legislative bills numbers S. 2677-A
26 and A. 463-A, is REPEALED.
27 § 8. Subdivision 5 of section 4903 of the public health law, as added
28 by chapter 705 of the laws of 1996, paragraph (b) as amended by chapter
29 586 of the laws of 1998, is amended to read as follows:
30 5. (a) Notice of an adverse determination made by a utilization review
31 agent shall be in writing and must include:
32 [(a)] (i) the reasons for the determination including the clinical
33 rationale, if any;
34 [(b)] (ii) instructions on how to initiate standard and expedited
35 appeals pursuant to section forty-nine hundred four and an external
36 appeal pursuant to section forty-nine hundred fourteen of this article;
37 [and
38 (c)] (iii) notice of the availability, upon request of the enrollee,
39 or the enrollee's designee, of the clinical review criteria relied upon
40 to make such determination. Such notice shall also specify what, if any,
41 additional necessary information must be provided to, or obtained by,
42 the utilization review agent in order to render a decision on the
43 appeal; and
44 (iv) for an adverse determination related to a step therapy protocol
45 override request, information that includes the clinical review criteria
46 relied upon to make such determination and any applicable alternative
47 prescription drugs subject to the step therapy protocol of the utiliza-
48 tion review agent.
49 (b) A utilization review agent may provide notice of an adverse deter-
50 mination related to a step therapy protocol override determination elec-
51 tronically pursuant to subdivision nine of this section, including by
52 electronic mail or through the health care plan's member portal and
53 provider portal. An electronic notice of such an adverse determination
54 may meet the requirements of subparagraph (iv) of paragraph (a) of this
55 subdivision by linking to information posted on the website of the
56 health care plan.
S. 8038 4
1 § 9. This act shall take effect on the same date and in the same
2 manner as a chapter of the laws of 2023 amending the insurance law and
3 the public health law relating to requiring notice of adverse step ther-
4 apy determinations, as proposed in legislative bills numbers S. 2677-A
5 and A. 463-A, takes effect.
