Bill Text: NY A10248 | 2011-2012 | General Assembly | Amended

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

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Bill Title: Directs the commissioner of health to develop a standard prior prescription drug authorization request form for managed care providers.

Spectrum: Partisan Bill (Democrat 59-3)

Status: (Passed) 2012-10-03 - signed chap.466 [A10248 Detail]

Download: New_York-2011-A10248-Amended.html

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                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                       10248--A
                                 I N  A S S E M B L Y
                                     May 16, 2012
                                      ___________
       Introduced  by  M.  of  A. P. RIVERA, GOTTFRIED, CAMARA, CASTRO, CRESPO,
         CYMBROWITZ,  SCARBOROUGH,  ARROYO,  AUBRY,  BROOK-KRASNY,   ZEBROWSKI,
         GIBSON,  N. RIVERA,  HOOPER,  RODRIGUEZ, GUNTHER, MAGNARELLI, ROBERTS,
         LIFTON,  LINARES,  ROSENTHAL,  JAFFEE,  BENEDETTO,  COLTON,  DINOWITZ,
         MONTESANO,  ABINANTI,  REILLY,  SIMANOWITZ,  MAISEL,  JACOBS, BURLING,
         BOYLAND, ABBATE, WEISENBERG, PERRY -- Multi-Sponsored by -- M.  of  A.
         BRENNAN,  BRONSON,  CLARK,  COOK,  CROUCH,  GLICK,  LATIMER,  LUPARDO,
         PEOPLES-STOKES, SWEENEY,  THIELE,  TITONE,  TITUS  --  read  once  and
         referred  to  the  Committee  on  Health -- committee discharged, bill
         amended, ordered reprinted as amended and recommitted to said  commit-
         tee
       AN ACT to amend the public health law and the insurance law, in relation
         to  utilization  review  and prior authorization for prescription drug
         benefits
         THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
       BLY, DO ENACT AS FOLLOWS:
    1    Section  1.  Subdivisions 2 and 7 of section 4903 of the public health
    2  law, subdivision 2 as added by chapter 705  of  the  laws  of  1996  and
    3  subdivision  7  as added by chapter 586 of the laws of 1998, are amended
    4  and a new subdivision 8 is added to read as follows:
    5    2. A utilization review agent shall make a utilization review determi-
    6  nation involving health care services  which  require  pre-authorization
    7  and  provide  notice  of  a  determination to the enrollee or enrollee's
    8  designee and the enrollee's health care provider  by  telephone  and  in
    9  writing  within three business days of receipt of the necessary informa-
   10  tion.  A UTILIZATION REVIEW AGENT SHALL MAKE A UTILIZATION REVIEW DETER-
   11  MINATION INVOLVING A REQUEST FOR PRESCRIPTION DRUG BENEFITS  WITHIN  TWO
   12  BUSINESS  DAYS  OF  RECEIPT OF THE NECESSARY INFORMATION, AND WITHIN ONE
   13  DAY IF THE REQUEST IS SUBMITTED BY ELECTRONIC MEANS.  AS  SET  FORTH  IN
   14  SUBDIVISION  EIGHT  OF  THIS  SECTION,  A UTILIZATION REVIEW AGENT SHALL
   15  ACCEPT THE MAKING OF SUCH REQUEST FOR PRESCRIPTION DRUG BENEFITS ON  THE
   16  STANDARD FORM TO BE DEVELOPED BY THE COMMISSIONER AND THE SUPERINTENDENT
   17  OF  FINANCIAL SERVICES UNDER SUBDIVISION EIGHT OF THIS SECTION. A HEALTH
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD15817-02-2
       A. 10248--A                         2
    1  CARE PLAN SHALL ACCEPT SUCH FORM AS SUFFICIENT TO REQUEST A  UTILIZATION
    2  REVIEW DETERMINATION FOR PRESCRIPTION DRUG BENEFITS.
    3    7.  Failure  by  the  utilization review agent to make a determination
    4  within the time periods prescribed in this section shall be deemed to be
    5  an adverse determination subject to appeal pursuant  to  section  [forty
    6  nine] FORTY-NINE hundred four of this title; PROVIDED, HOWEVER, THAT THE
    7  FAILURE  BY  THE  UTILIZATION  REVIEW  AGENT TO MAKE A DETERMINATION FOR
    8  PRESCRIPTION DRUG BENEFITS WITHIN THE TIME FRAMES SPECIFIED IN  SUBDIVI-
    9  SION TWO OF THIS SECTION SHALL BE DEEMED TO BE AN APPROVAL.
   10    8.  (A)  THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL SERVICES
   11  SHALL JOINTLY DEVELOP A STANDARD FORM FOR  REQUESTS  FOR  A  UTILIZATION
   12  REVIEW  DETERMINATION  FOR  PRESCRIPTION  DRUG  BENEFITS AS SET FORTH IN
   13  SUBDIVISION TWO OF THIS SECTION. A  PRESCRIBING  PROVIDER  MAY  USE  THE
   14  STANDARD  FORM, AND SHALL USE IT IF REQUIRED BY THE HEALTH CARE PLAN, TO
   15  REQUEST A UTILIZATION REVIEW DETERMINATION FOR PRESCRIPTION  DRUG  BENE-
   16  FITS.  EVERY  HEALTH  CARE PLAN SHALL ACCEPT THE STANDARD FORM AS SUFFI-
   17  CIENT TO REQUEST A UTILIZATION  REVIEW  DETERMINATION  FOR  PRESCRIPTION
   18  DRUG BENEFITS.
   19    (B)  THE  STANDARD  FORM  DEVELOPED  PURSUANT TO PARAGRAPH (A) OF THIS
   20  SUBDIVISION SHALL BE MADE ELECTRONICALLY AVAILABLE BY THE DEPARTMENT AND
   21  THE HEALTH CARE PLAN.  THE COMPLETED STANDARD FORM MAY BE  SUBMITTED  BY
   22  THE  PRESCRIBING  PROVIDER  TO THE HEALTH CARE PLAN ELECTRONICALLY OR IN
   23  PHYSICAL FORM.
   24    S 2. Subsections (b) and (g) of section 4903  of  the  insurance  law,
   25  subsection  (b)  as  added  by  chapter  705  of  the  laws  of 1996 and
   26  subsection (g) as added by chapter 586 of the laws of 1998, are  amended
   27  and a new subsection (h) is added to read as follows:
   28    (b)  A utilization review agent shall make a utilization review deter-
   29  mination involving health care services which require  pre-authorization
   30  and provide notice of a determination to the insured or insured's desig-
   31  nee  and  the insured's health care provider by telephone and in writing
   32  within three business days of receipt of the necessary information.    A
   33  UTILIZATION  REVIEW  AGENT SHALL MAKE A UTILIZATION REVIEW DETERMINATION
   34  INVOLVING A REQUEST FOR PRESCRIPTION DRUG BENEFITS WITHIN  TWO  BUSINESS
   35  DAYS  OF RECEIPT OF THE NECESSARY INFORMATION, AND WITHIN ONE DAY IF THE
   36  REQUEST IS SUBMITTED BY ELECTRONIC MEANS.   AS SET FORTH  IN  SUBSECTION
   37  (H)  OF THIS SECTION, A UTILIZATION REVIEW AGENT SHALL ACCEPT THE MAKING
   38  OF SUCH REQUEST ON THE STANDARD FORM DEVELOPED BY  THE  COMMISSIONER  OF
   39  HEALTH  AND  THE  SUPERINTENDENT  PURSUANT  TO  SUBSECTION  (H)  OF THIS
   40  SECTION.  A HEALTH CARE PLAN SHALL ACCEPT SUCH  FORM  AS  SUFFICIENT  TO
   41  REQUEST  A  UTILIZATION REVIEW DETERMINATION FOR PRESCRIPTION DRUG BENE-
   42  FITS.
   43    (g) Failure by the utilization review agent to  make  a  determination
   44  within the time periods prescribed in this section shall be deemed to be
   45  an  adverse  determination  subject  to  appeal pursuant to section four
   46  thousand nine hundred four of this title; PROVIDED,  HOWEVER,  THAT  THE
   47  FAILURE  BY  THE  UTILIZATION  REVIEW  AGENT TO MAKE A DETERMINATION FOR
   48  PRESCRIPTION  DRUG  BENEFITS  WITHIN  THE  TIME  FRAMES   SPECIFIED   IN
   49  SUBSECTION (B) OF THIS SECTION SHALL BE DEEMED TO BE AN APPROVAL.
   50    (H) (1) THE COMMISSIONER OF HEALTH AND THE SUPERINTENDENT SHALL JOINT-
   51  LY  DEVELOP A STANDARD FORM FOR REQUESTS FOR A UTILIZATION REVIEW DETER-
   52  MINATION FOR PRESCRIPTION DRUG BENEFITS AS SET FORTH IN  SUBSECTION  (B)
   53  OF  THIS  SECTION. A PRESCRIBING PROVIDER MAY USE THE STANDARD FORM, AND
   54  SHALL USE IT IF REQUIRED BY THE HEALTH CARE PLAN, TO REQUEST A  UTILIZA-
   55  TION  REVIEW  DETERMINATION FOR PRESCRIPTION DRUG BENEFITS. EVERY HEALTH
       A. 10248--A                         3
    1  CARE PLAN SHALL ACCEPT THE STANDARD FORM  AS  SUFFICIENT  TO  REQUEST  A
    2  UTILIZATION REVIEW DETERMINATION FOR PRESCRIPTION DRUG BENEFITS.
    3    (2)  THE  STANDARD  FORM  DEVELOPED  PURSUANT TO PARAGRAPH ONE OF THIS
    4  SUBSECTION SHALL BE MADE ELECTRONICALLY AVAILABLE BY THE DEPARTMENT  AND
    5  THE  HEALTH  CARE  PLAN. THE COMPLETED STANDARD FORM MAY BE SUBMITTED BY
    6  THE PRESCRIBING PROVIDER TO THE HEALTH CARE PLAN  ELECTRONICALLY  OR  IN
    7  PHYSICAL FORM.
    8    S  3.  This  act  shall  take  effect April 1, 2013, provided that the
    9  commissioner of health and the superintendent of financial services  are
   10  authorized to take any actions, including developing and providing forms
   11  and  making regulations, under section 4903 of the public health law and
   12  section 4903 of the insurance law, as amended by  this  act,  to  enable
   13  those amendments to be implemented on that date.