Bill Text: NY A05411 | 2021-2022 | General Assembly | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2022-05-31 - substituted by s4620c [A05411 Detail]
Download: New_York-2021-A05411-Introduced.html
Bill Title: Requires health plans operating in the state to furnish the cost, benefit, and coverage data as required to the enrollee, his or her health care provider, or the third-party of his or her choosing.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2022-05-31 - substituted by s4620c [A05411 Detail]
Download: New_York-2021-A05411-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 5411 2021-2022 Regular Sessions IN ASSEMBLY February 16, 2021 ___________ Introduced by M. of A. McDONALD -- read once and referred to the Commit- tee on Insurance AN ACT to amend the insurance law, in relation to enacting the "patient Rx information and choice expansion act" The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. This act shall be known and may be cited as the "patient Rx 2 information and choice expansion act" or the "PRICE act". 3 § 2. The insurance law is amended by adding a new section 341-a to 4 read as follows: 5 § 341-a. Patient prescription pricing transparency. 1. Definitions. 6 As used in this section: 7 (a) "Health plan" means benefits provided by any entity delivering or 8 issuing for delivery a policy of accident and health insurance pursuant 9 to section three thousand two hundred sixteen, or a group or blanket 10 accident and health insurance policy pursuant to section three thousand 11 two hundred twenty-one, or providing benefits pursuant to section four 12 thousand three hundred three of this chapter. 13 (b) "Cost-sharing information" means the amount an enrollee is 14 required to pay in order to receive a drug that is covered under the 15 enrollee's health plan. 16 (c) "Covered/coverage" means those health care services to which an 17 enrollee is entitled under the terms of the health plan. 18 (d) "Enrollee" means the covered individual, policyholder, subscriber, 19 the insured, or person who has authority under applicable law to act on 20 behalf of an enrollee in making decisions related to health care, a 21 health plan, or pharmacy benefit manager, or its affiliates or entities. 22 (e) "Interoperability element" means hardware, software, integrated 23 technologies or related licenses, technical information, privileges, 24 rights, intellectual property, upgrades, or services that may be neces- EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD08942-01-1A. 5411 2 1 sary to provide the data required in the requested format and consistent 2 with the required format. 3 (f) "Pharmacy benefit manager (PBM)" ensure that this term includes 4 pharmacy benefit managers, affiliates, or other entities acting on their 5 behalf. 6 (g) "Electronic health record" means a digital version of a patient's 7 paper chart and medical history that makes information available 8 instantly and securely to authorized users. 9 (h) "Electronic prescribing system" means a system that enables pres- 10 cribers to enter prescription information into a computer prescription 11 device and securely transmit the prescription to pharmacies using a 12 special software program and connectivity to a transmission network. 13 (i) "Electronic prescription" means an electronic prescription as 14 defined in section thirty-three hundred two of the public health law. 15 (j) "Prescriber" means a health care provider licensed to prescribe 16 medication or medical devices in the state. 17 (k) "Real-time benefit tool" or "RTBT" means an electronic 18 prescription decision support tool that: (i) is capable of integrating 19 with prescribers' electronic prescribing and electronic health record 20 systems; and (ii) complies with the technical standards adopted by the 21 National Council for Prescription Drug Programs (NCPDP). 22 2. No later than July first, two thousand twenty-three, each health 23 plan operating in the state shall, upon request of the enrollee, his or 24 her health care provider, or a third-party on their behalf, furnish the 25 cost, benefit, and coverage data set forth as required to the enrollee, 26 his or her health care provider, or the third-party of his or her choos- 27 ing and shall ensure that such data is (i) current no later than one 28 business day after any change is made; (ii) provided in real time; and 29 (iii) in the same format that the request is made by the enrollee or his 30 or her health care provider. 31 3. The format of the request shall use established industry content 32 and transport standards published by: 33 (a) A standards developing organization accredited by the American 34 National Standards Institute (ANSI), including, the National Council for 35 Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or 36 (b) A relevant federal or state governing body, including the Center 37 for Medicare & Medicaid Services or the Office of the National Coordina- 38 tor for Health Information Technology. 39 4. A facsimile, proprietary payor or patient portal, or other elec- 40 tronic form shall not be considered acceptable electronic formats pursu- 41 ant to this section. 42 5. Upon such request, the following data shall be provided for any 43 drug covered under the enrollee's health plan: 44 (a) patient-specific eligibility information; 45 (b) patient-specific prescription cost and benefit data, such as 46 applicable formulary, benefit, coverage and cost-sharing data for the 47 prescribed drug and clinically-appropriate alternatives, when appropri- 48 ate; 49 (c) patient-specific cost-sharing information that describes variance 50 in cost-sharing based on the pharmacy dispensing the prescribed drug or 51 its alternatives, and in relation to the patient's benefit (i.e., spend 52 related to out-of-pocket maximum); 53 (d) information regarding lower cost clinically-appropriate treatment 54 alternatives; andA. 5411 3 1 (e) applicable utilization management requirements, such as prior 2 authorization, step therapy, quantity limits, and site-of-service 3 restrictions. 4 6. Any health plan or PBM shall furnish the data as required whether 5 the request is made using the drug's unique billing code, such as a 6 National Drug Code or Healthcare Common Procedure Coding System code or 7 descriptive term, such as the brand or generic name of the drug. A 8 health plan or PBM shall not deny or delay a request as a method of 9 blocking the data set forth as required from being shared based on how 10 the drug was requested. 11 7. A health plan, or entities acting on a health plan's behalf, shall 12 not restrict, prohibit, or otherwise hinder the prescriber from commu- 13 nicating or sharing benefit and coverage information that reflects other 14 choices, such as cash price, lower cost clinically-appropriate alterna- 15 tives, whether or not they are covered under the enrollee's plan, 16 patient assistance and support programs and the cost available at the 17 patient's pharmacy of choice. 18 8. A health plan, or entities acting on a health plan's behalf, shall 19 not, except as may be required by law, interfere with, prevent, or mate- 20 rially discourage access, exchange, or use of the data as required, 21 which may include charging fees, not responding to a request at the time 22 made where such a response is reasonably possible, implementing technol- 23 ogy in nonstandard ways or instituting enrollee consent requirements, 24 processes, policies, procedures, or renewals that are likely to substan- 25 tially increase the complexity or burden of accessing, exchanging, or 26 using such data; nor penalize a health care provider or professional for 27 disclosing such information to an enrollee or prescribing, administer- 28 ing, or ordering a clinically appropriate or lower-cost alternative. 29 9. Nothing in this section shall be construed to limit access to the 30 most up-to-date patient-specific eligibility or patient-specific 31 prescription cost and benefit data by the health plan. 32 10. Nothing in this section shall interfere with patient choice and a 33 health care professional's ability to convey the full range of 34 prescription drug cost options to a patient. Health plans, or entities 35 acting on their behalf, shall not restrict a health care professional 36 from communicating to the patient prescription cost options. 37 11. No RTBT shall require or influence a patient to utilize specific 38 plan preferred drugs or pharmacies. 39 § 3. This act shall take effect July 1, 2023. Effective immediately, 40 the addition, amendment and/or repeal of any rule or regulation neces- 41 sary for the implementation of this act on its effective date are 42 authorized to be made and completed on or before such effective date.
