Bill Text: NY A09265 | 2021-2022 | General Assembly | Introduced
Bill Title: Requires written notice of an adverse determination made by a utilization review agent in relation to a step therapy protocol override determination.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2022-02-09 - referred to insurance [A09265 Detail]
Download: New_York-2021-A09265-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 9265 IN ASSEMBLY February 9, 2022 ___________ 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 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 § 2. Section 4903 of the insurance law is amended by adding a new 18 subsection (e-1) to read as follows: 19 (e-1) Notice of an adverse determination made by a utilization review 20 agent in relation to a step therapy protocol override determination 21 request shall be made in writing to the insured or the insured's author- 22 ized representative and the insured's prescribing health care profes- 23 sional as defined in subsection (f) of section forty-nine hundred of 24 this chapter, and shall include: 25 (i) the reasons for the determination including the clinical ration- 26 ale, if any; 27 (ii) instructions on how to initiate standard and expedited appeals 28 pursuant to section four thousand nine hundred four of this article and EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD14434-01-2A. 9265 2 1 an external appeal pursuant to section four thousand nine hundred four- 2 teen of this article; 3 (iii) information that includes: any applicable alternative covered 4 medications; the clinical review criteria relied upon to make such 5 determination; and any additional necessary information that must be 6 provided to, or obtained by, the utilization review agent in order to 7 render a decision on the appeal. 8 § 3. Subdivision 1 of section 4902 of the public health law is amended 9 by adding a new paragraph (l) to read as follows: 10 (l) Establishment of a written procedure to assure that the notice of 11 an adverse determination in relation to a step therapy protocol override 12 determination request includes: (i) the reasons for the determination 13 including the clinical rationale, if any; (ii) instructions on how to 14 initiate standard and expedited appeals pursuant to subdivision two of 15 section forty-nine hundred four of this title and an external appeal 16 pursuant to section forty-nine hundred fourteen of this article; (iii) 17 information that includes: any applicable alternative covered medica- 18 tions; the clinical review criteria relied upon to make such determi- 19 nation; and any additional necessary information that must be provided 20 to, or obtained by, the utilization review agent in order to render a 21 decision on the appeal. 22 § 4. Section 4903 of the public health law is amended by adding a new 23 subdivision 5-a to read as follows: 24 5-a. Notice of an adverse determination made by a utilization review 25 agent in relation to a step therapy protocol override determination 26 request shall be made in writing to the enrollee or the enrollee's 27 authorized representative and the enrollee's prescribing health care 28 professional as defined in subdivision six of section forty-nine hundred 29 of this title, and shall include: 30 (a) the reasons for the determination including the clinical ration- 31 ale, if any; 32 (b) instructions on how to initiate standard and expedited appeals 33 pursuant to section forty-nine hundred four of this title and an 34 external appeal pursuant to section forty-nine hundred fourteen of this 35 article; 36 (c) information that includes: any applicable alternative covered 37 medications; the clinical review criteria relied upon to make such 38 determination; and any additional necessary information that must be 39 provided to, or obtained by, the utilization review agent in order to 40 render a decision on the appeal. 41 § 5. This act shall take effect on the ninetieth day after it shall 42 have become a law. Effective immediately, the addition, amendment and/or 43 repeal of any rule or regulation necessary for the implementation of 44 this act on its effective date are authorized to be made and completed 45 on or before such effective date.