Bill Text: NY A05411 | 2021-2022 | General Assembly | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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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-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                         5411--B

                               2021-2022 Regular Sessions

                   IN ASSEMBLY

                                    February 16, 2021
                                       ___________

        Introduced  by M. of A. McDONALD, THIELE, ENGLEBRIGHT, BURDICK, MONTESA-
          NO, SCHMITT, REILLY, LAWLER, McDONOUGH, LEMONDES,  DICKENS,  SILLITTI,
          CUSICK,  SIMON,  ANGELINO,  SALKA, DURSO, JACKSON, GUNTHER, GOTTFRIED,
          STECK, HAWLEY, FORREST -- read once and referred to the  Committee  on
          Insurance  -- committee discharged, bill amended, ordered reprinted as
          amended and recommitted  to  said  committee  --  recommitted  to  the
          Committee  on  Insurance in accordance with Assembly Rule 3, sec. 2 --
          committee discharged, bill amended, ordered reprinted as  amended  and
          recommitted to said committee

        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.

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD08942-04-1
        A. 5411--B                          2

     1    (d) "Enrollee" means the covered individual, policyholder, subscriber,
     2  the  insured, or person who has authority under applicable law to act on
     3  behalf of an enrollee in making decisions  related  to  health  care,  a
     4  health plan, or pharmacy benefit manager, or its affiliates or entities.
     5    (e)  "Interoperability  element"  means hardware, software, integrated
     6  technologies or related  licenses,  technical  information,  privileges,
     7  rights,  intellectual property, upgrades, or services that may be neces-
     8  sary to provide the data required in the requested format and consistent
     9  with the required format.
    10    (f) "Pharmacy benefit manager (PBM)" ensure that  this  term  includes
    11  pharmacy benefit managers, affiliates, or other entities acting on their
    12  behalf.
    13    (g)  "Electronic health record" means a digital version of a patient's
    14  paper  chart  and  medical  history  that  makes  information  available
    15  instantly and securely to authorized users.
    16    (h)  "Electronic prescribing system" means a system that enables pres-
    17  cribers to enter prescription information into a  computer  prescription
    18  device  and  securely  transmit  the  prescription to pharmacies using a
    19  special software program and connectivity to a transmission network.
    20    (i) "Electronic prescription"  means  an  electronic  prescription  as
    21  defined in section thirty-three hundred two of the public health law.
    22    (j)  "Prescriber"  means  a health care provider licensed to prescribe
    23  medication or medical devices in the state.
    24    (k)  "Real-time  benefit  tool"  or   "RTBT"   means   an   electronic
    25  prescription  decision  support tool that: (i) is capable of integrating
    26  with prescribers' electronic prescribing and  electronic  health  record
    27  systems;  and  (ii) complies with the technical standards adopted by the
    28  National Council for Prescription Drug Programs (NCPDP).
    29    2. No later than July first, two thousand  twenty-three,  each  health
    30  plan  operating in the state shall, upon request of the enrollee, his or
    31  her health care provider, or a third-party on their behalf, furnish  the
    32  cost,  benefit, and coverage data set forth as required to the enrollee,
    33  his or her health care provider, or the third-party of his or her choos-
    34  ing and shall ensure that such data is (i) current  no  later  than  one
    35  business  day  after any change is made; (ii) provided in real time; and
    36  (iii) in the same format that the request is made by the enrollee or his
    37  or her health care provider.
    38    3. The format of the request shall use  established  industry  content
    39  and transport standards published by:
    40    (a)  A  standards  developing  organization accredited by the American
    41  National Standards Institute (ANSI), including, the National Council for
    42  Prescription Drug Programs (NCPDP), ASC X12, Health Level 7; or
    43    (b) A relevant federal or state governing body, including  the  Center
    44  for Medicare & Medicaid Services or the Office of the National Coordina-
    45  tor for Health Information Technology.
    46    4.  A  facsimile,  proprietary payor or patient portal, or other elec-
    47  tronic form shall not be considered acceptable electronic formats pursu-
    48  ant to this section.
    49    5. Upon such request, the following data shall  be  provided  for  any
    50  drug covered under the enrollee's health plan:
    51    (a) patient-specific eligibility information;
    52    (b)  patient-specific  prescription  cost  and  benefit  data, such as
    53  applicable formulary, benefit, coverage and cost-sharing  data  for  the
    54  prescribed  drug and clinically-appropriate alternatives, when appropri-
    55  ate;
        A. 5411--B                          3

     1    (c) patient-specific cost-sharing information that describes  variance
     2  in  cost-sharing based on the pharmacy dispensing the prescribed drug or
     3  its alternatives, and in relation to the patient's benefit (i.e.,  spend
     4  related to out-of-pocket maximum);
     5    (d)  information regarding lower cost clinically-appropriate treatment
     6  alternatives; and
     7    (e) applicable utilization management requirements.
     8    6. Any health plan or PBM shall furnish the data as  required  whether
     9  the  request  is  made  using  the drug's unique billing code, such as a
    10  National Drug Code or Healthcare Common Procedure Coding System code  or
    11  descriptive term. A health plan or PBM shall not deny or delay a request
    12  as a method of blocking the data set forth as required from being shared
    13  based on how the drug was requested.
    14    7.  A health plan, or entities acting on a health plan's behalf, shall
    15  not restrict, prohibit, or otherwise hinder  the prescriber from  commu-
    16  nicating or sharing benefit and coverage information that reflects other
    17  choices,  such as cash price, lower cost clinically-appropriate alterna-
    18  tives, whether or not  they  are  covered  under  the  enrollee's  plan,
    19  patient  assistance  and  support programs and the cost available at the
    20  patient's pharmacy of choice.
    21    8. A health plan, or entities acting on a health plan's behalf,  shall
    22  not, except as may be required by law, interfere with, prevent, or mate-
    23  rially  discourage  access,  exchange,  or  use of the data as required,
    24  which may include charging fees, not responding to a request at the time
    25  made where such a response is reasonably possible, implementing technol-
    26  ogy in nonstandard ways or instituting  enrollee  consent  requirements,
    27  processes, policies, procedures, or renewals that are likely to substan-
    28  tially  increase  the  complexity or burden of accessing, exchanging, or
    29  using such data; nor penalize a health care provider or professional for
    30  disclosing such information to an enrollee or  prescribing,  administer-
    31  ing, or ordering a clinically appropriate or lower-cost alternative.
    32    9.  Nothing  in this section shall be construed to limit access to the
    33  most  up-to-date  patient-specific   eligibility   or   patient-specific
    34  prescription cost and benefit data by the health plan.
    35    10.  Nothing in this section shall interfere with patient choice and a
    36  health  care  professional's  ability  to  convey  the  full  range   of
    37  prescription  drug cost options to a patient.  Health plans, or entities
    38  acting on their behalf, shall not restrict a  health  care  professional
    39  from communicating to the patient prescription cost options.
    40    11.  No  RTBT shall require or influence a patient to utilize specific
    41  plan preferred drugs or pharmacies.
    42    § 3.  Severability. If any provision of this act, or  any  application
    43  of  any  provision of this  act, is held to be invalid, or to violate or
    44  be inconsistent with any   federal law or  regulation,  that  shall  not
    45  affect  the  validity  or   effectiveness of any other provision of this
    46  act, or of any other  application of any provision of  this  act,  which
    47  can  be given effect  without that provision or application; and to that
    48  end, the provisions  and applications of this act are severable.
    49    § 4. This act shall take effect July 1, 2023.  Effective  immediately,
    50  the  addition,  amendment and/or repeal of any rule or regulation neces-
    51  sary for the implementation of  this  act  on  its  effective  date  are
    52  authorized to be made and completed on or before such effective date.