Bill Text: NY S07872 | 2017-2018 | General Assembly | Introduced
Bill Title: Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; amends provisions relating to prescription drug formulary changes and pre-authorization for certain health care services.
Spectrum: Slight Partisan Bill (Republican 7-4)
Status: (Introduced - Dead) 2018-03-05 - REFERRED TO HEALTH [S07872 Detail]
Download: New_York-2017-S07872-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 7872 IN SENATE March 5, 2018 ___________ Introduced by Sen. HANNON -- read twice and ordered printed, and when printed to be committed to the Committee on Health AN ACT to amend the public health law and the insurance law, in relation to utilization review program standards and prescription drug formu- lary changes during a contract year, and in relation to pre-authoriza- tion of health care services The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Paragraph (c) of subdivision 1 of section 4902 of the 2 public health law, as added by chapter 705 of the laws of 1996, is 3 amended to read as follows: 4 (c) Utilization of written clinical review criteria developed pursuant 5 to a utilization review plan. Such clinical review criteria shall 6 utilize recognized evidence-based and peer reviewed clinical review 7 criteria that takes into account the needs of atypical patient popu- 8 lations and diagnoses; 9 § 2. Paragraph (a) of subdivision 2 of section 4903 of the public 10 health law, as amended by chapter 371 of the laws of 2015, is amended to 11 read as follows: 12 (a) A utilization review agent shall make a utilization review deter- 13 mination involving health care services which require pre-authorization 14 and provide notice of a determination to the enrollee or enrollee's 15 designee and the enrollee's health care provider by telephone and in 16 writing within [three business days] forty-eight hours of receipt of the 17 necessary information, or within twenty-four hours of the receipt of 18 necessary information if the request is for an enrollee with a medical 19 condition that places the health of the insured in serious jeopardy 20 without the health care services recommended by the enrollee's health 21 care professional. To the extent practicable, such written notification 22 to the enrollee's health care provider shall be transmitted electron- 23 ically, in a manner and in a form agreed upon by the parties. The 24 notification shall identify; (i) whether the services are considered 25 in-network or out-of-network; (ii) and whether the enrollee will be held 26 harmless for the services and not be responsible for any payment, other EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD11465-05-8S. 7872 2 1 than any applicable co-payment or co-insurance; (iii) as applicable, the 2 dollar amount the health care plan will pay if the service is out-of- 3 network; and (iv) as applicable, information explaining how an enrollee 4 may determine the anticipated out-of-pocket cost for out-of-network 5 health care services in a geographical area or zip code based upon the 6 difference between what the health care plan will reimburse for out-of- 7 network health care services and the usual and customary cost for out- 8 of-network health care services. An approval for a request for pre-au- 9 thorization shall be valid for the duration of the prescription or 10 treatment as requested by the enrollee's health care provider. 11 § 3. The public health law is amended by adding a new section 4909 to 12 read as follows: 13 § 4909. Prescription drug formulary changes. 1. A health care plan 14 required to provide essential health benefits shall not, except as 15 otherwise provided in subdivision two of this section, remove a 16 prescription drug from a formulary: 17 (a) if the formulary includes two or more tiers of benefits providing 18 for different deductibles, copayments or coinsurance applicable to the 19 prescription drugs in each tier, move a drug to a tier with a larger 20 deductible, copayment or coinsurance, or 21 (b) add utilization management restrictions to a formulary drug, 22 unless such changes occur at the time of enrollment or issuance of 23 coverage. Such prohibition shall apply beginning on the date on which 24 open enrollment begins for a plan year and through the end of the plan 25 year to which such open enrollment period applies. 26 2. (a) A health care plan with a formulary that includes two or more 27 tiers of benefits providing for different deductibles, copayments or 28 coinsurance applicable to prescription drugs in each tier may move a 29 prescription drug to a tier with a larger deducible, copayment or coin- 30 surance if an AB-rated generic drug for such prescription drug is added 31 to the formulary at the same time. 32 (b) A health care plan may remove a prescription drug from a formulary 33 if the federal food and drug administration determines that such drug 34 should be removed from the market. 35 § 4. Paragraph 3 of subsection (a) of section 4902 of the insurance 36 law, as added by chapter 705 of the laws of 1996, is amended to read as 37 follows: 38 (3) Utilization of written clinical review criteria developed pursuant 39 to a utilization review plan. Such clinical review criteria shall 40 utilize recognized evidence-based and peer reviewed clinical review 41 criteria that takes into account the needs of atypical patient popu- 42 lations and diagnoses; 43 § 5. Paragraph 1 of subsection (b) of section 4903 of the insurance 44 law, as amended by chapter 371 of the laws of 2015, is amended to read 45 as follows: 46 (1) A utilization review agent shall make a utilization review deter- 47 mination involving health care services which require pre-authorization 48 and provide notice of a determination to the insured or insured's desig- 49 nee and the insured's health care provider by telephone and in writing 50 within [three business days] forty-eight hours of receipt of the neces- 51 sary information, or within twenty-four hours of the receipt of neces- 52 sary information if the request is for an insured with a medical condi- 53 tion that places the health of the insured in serious jeopardy without 54 the health care services recommended by the insured's health care 55 provider. To the extent practicable, such written notification to the 56 enrollee's health care provider shall be transmitted electronically, inS. 7872 3 1 a manner and in a form agreed upon by the parties. The notification 2 shall identify: (i) whether the services are considered in-network or 3 out-of-network; (ii) whether the insured will be held harmless for the 4 services and not be responsible for any payment, other than any applica- 5 ble co-payment, co-insurance or deductible; (iii) as applicable, the 6 dollar amount the health care plan will pay if the service is out-of- 7 network; and (iv) as applicable, information explaining how an insured 8 may determine the anticipated out-of-pocket cost for out-of-network 9 health care services in a geographical area or zip code based upon the 10 difference between what the health care plan will reimburse for out-of- 11 network health care services and the usual and customary cost for out- 12 of-network health care services. An approval of request for pre-author- 13 ization shall be valid for the duration of the prescription or treatment 14 requested for pre-authorization. 15 § 6. The insurance law is amended by adding a new section 4909 to read 16 as follows: 17 § 4909. Prescription drug formulary changes. (a) A health care plan 18 required to provide essential health benefits shall not, except as 19 otherwise provided in subsection (b) of this section, remove a 20 prescription drug from a formulary: 21 (i) if the formulary includes two or more tiers of benefits providing 22 for different deductibles, copayments or coinsurance applicable to the 23 prescription drugs in each tier, move a drug to a tier with a larger 24 deductible, copayment or coinsurance, or 25 (ii) add utilization management restrictions to a formulary drug, 26 unless such changes occur at the time of enrollment or issuance of 27 coverage. Such prohibition shall apply beginning on the date on which 28 open enrollment begins for a plan year and through the end of the plan 29 year to which such open enrollment period applies. 30 (b) (i) A health care plan with a formulary that includes two or more 31 tiers of benefits providing for different deductibles, copayments or 32 coinsurance applicable to prescription drugs in each tier may move a 33 prescription drug to a tier with a larger deducible, copayment or coin- 34 surance if an AB-rated generic drug for such prescription drug is added 35 to the formulary at the same time. 36 (ii) A health care plan may remove a prescription drug from a formu- 37 lary if the federal food and drug administration determines that such 38 drug should be removed from the market. 39 § 7. Subsection (a) of section 3238 of the insurance law, as added by 40 chapter 451 of the laws of 2007, is amended to read as follows: 41 (a) An insurer, corporation organized pursuant to article forty-three 42 of this chapter, municipal cooperative health benefits plan certified 43 pursuant to article forty-seven of this chapter, or health maintenance 44 organization and other organizations certified pursuant to article 45 forty-four of the public health law ("health plan") shall pay claims for 46 a health care service for which a pre-authorization was required by, and 47 received from, the health plan prior to the rendering of such health 48 care service, and eligibility confirmed on the day of the service, 49 unless: 50 (1) [(i) the insured, subscriber, or enrollee was not a covered person51at the time the health care service was rendered.52(ii) Notwithstanding the provisions of subparagraph (i) of this para-53graph, a health plan shall not deny a claim on this basis if the54insured's, subscriber's or enrollee's coverage was retroactively termi-55nated more than one hundred twenty days after the date of the health56care service, provided that the claim is submitted within ninety daysS. 7872 4 1after the date of the health care service. If the claim is submitted2more than ninety days after the date of the health care service, the3health plan shall have thirty days after the claim is received to deny4the claim on the basis that the insured, subscriber or enrollee was not5a covered person on the date of the health care service.6(2)] the submission of the claim with respect to an insured, subscrib- 7 er or enrollee was not timely under the terms of the applicable provider 8 contract, if the claim is submitted by a provider, or the policy or 9 contract, if the claim is submitted by the insured, subscriber or enrol- 10 lee; 11 [(3)] (2) at the time the pre-authorization was issued, the insured, 12 subscriber or enrollee had not exhausted contract or policy benefit 13 limitations based on information available to the health plan at such 14 time, but subsequently exhausted contract or policy benefit limitations 15 after authorization was issued; provided, however, that the health plan 16 shall include in the notice of determination required pursuant to 17 subsection (b) of section four thousand nine hundred three of this chap- 18 ter and subdivision two of section forty-nine hundred three of the 19 public health law that the visits authorized might exceed the limits of 20 the contract or policy and accordingly would not be covered under the 21 contract or policy; 22 [(4)] (3) the pre-authorization was based on materially inaccurate or 23 incomplete information provided by the insured, subscriber or enrollee, 24 the designee of the insured, subscriber or enrollee, or the health care 25 provider such that if the correct or complete information had been 26 provided, such pre-authorization would not have been granted; or 27 [(5) the pre-authorized service was related to a pre-existing condi-28tion that was excluded from coverage; or29(6)] (4) there is a reasonable basis supported by specific information 30 available for review by the superintendent that the insured, subscriber 31 or enrollee, the designee of the insured, subscriber or enrollee, or the 32 health care provider has engaged in fraud or abuse. 33 § 8. This act shall take effect on the ninetieth day after it shall 34 have become a law.
