Bill Text: NY A08501 | 2023-2024 | General Assembly | Introduced

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Bill Title: 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.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Passed) 2024-02-07 - signed chap.28 [A08501 Detail]

Download: New_York-2023-A08501-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          8501

                   IN ASSEMBLY

                                     January 4, 2024
                                       ___________

        Introduced by M. of A. McDONALD -- read once and referred to the Commit-
          tee on Insurance

        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     5  numbers S. 2677-A and A. 463-A, is REPEALED.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
        A. 8501                             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
        A. 8501                             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.
        A. 8501                             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.