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.