NY State Senate Bill 2021-S8798

Senate Bill S8798

2021-2022 Legislative Session

Relates to reporting information regarding step therapy override requests and determinations; repealer

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Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Apr 18, 2022	referred to insurance

co-Sponsors

2021-S8798 (ACTIVE) - Details

See Assembly Version of this Bill:: A9206
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§4903 & 4408, rpld §4408 sub 2 ¶(j), Pub Health L; rpld §3217-a sub§ (b) ¶10, §4324 sub§ (b) ¶10, amd §§3217-a, 4903 & 4324, Ins L
Versions Introduced in 2023-2024 Legislative Session:: S2800, A1384

2021-S8798 (ACTIVE) - Summary

Requires disclosure, in such form as the superintendent shall require, of non-confidential information regarding step therapy override requests and determinations on a website that is readily accessible to the public.

2021-S8798 (ACTIVE) - Sponsor Memo

                                 
BILL NUMBER: S8798

SPONSOR: BRESLIN
 
TITLE OF BILL:

An act to amend the insurance law and the public health law, in relation
to enhanced disclosure of step therapy override requests and determi-
nations; and to repeal certain provisions of such laws relating thereto

 
PURPOSE OR GENERAL IDEA OF BILL:

The purpose of this bill is to require insurers and utilization review
agents to report to the Department of Financial Services (DFS) and
require insurers and certain health organizations to make publicly
available certain information on step therapy override requests,
appeals, and their outcomes.

 
SUMMARY OF PROVISIONS:

Section one amends section 4903 of the insurance law to require each
health care plan and utilization review agents to annually report infor-
mation to DFS regarding step therapy override requests and determi-

nations. The report must include, but is not limited to, the number of
step therapy override determination requests. In addition, the report
must include the type of health care providers submitting requests. The
report must include the number of step therapy override determination
requests that were initially denied and the reasons for such denials.
The report must include the number of step therapy override determi-
nation requests that were initially approved and the number of requests
that were reversed upon appeal.

The utilization review agent is also required to disclose the same non-
confidential information, listed above, in a form the Superintendent
requires and must post on a readily accessible website.

Section two amends section 4903 of the public health law with the same
requirements as section one.

Section three repeals section 3217-a of the insurance law and adds three
new subsections. New subsection (g) requires each insurer subject to
this article to disclose information on step therapy protocols, step
therapy override determinations, internal and external appeals, and
associated clinical review information on a publicly accessible website
and upon request in written or electronic form. Subsection (h) requires
such insurers to update their websites with information related to any
new requirement or restrictions before implementation. Finally,
subsection (i) requires such insurers to provide any insured or health
care professional who may be impacted by any new requirements,
restrictions, or amendments with written notice no less than 60 days
before implementation.

Section four repeals subsection (b) of section 4324 of the insurance law
and adds three new subsections similar to the amendments from section
three. These disclosure requirements apply to each health service,
hospital service, or medical indemnity corporation subject to this arti-
cle.

Section five repeals subdivision two of section 4408 of the public
health law and adds three new subdivisions similar to the amendments
made in sections three and four of this bill. These disclosure require-
ments apply to each health maintenance organization subject to this
article.

Section six requires that this act shall take effect immediately.

 
JUSTIFICATION:

Reporting requirements are essential to understand whether insurers are
complying with the law. It also allows patients and providers equal
access to information. Publication of step therapy data also provides
the patients, health care professionals, and policymakers the opportu-
nity to identify potential violations of the law and room for improve-
ment.

 
PRIOR LEGISLATIVE HISTORY:

New Bill

 
FISCAL IMPLICATIONS:

None

 
EFFECTIVE DATE:
This act shall take effect immediately.

2021-S8798 (ACTIVE) - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   8798
 
                             I N  S E N A T E
 
                              April 18, 2022
                                ___________
 
 Introduced  by  Sen. BRESLIN -- read twice and ordered printed, and when
   printed to be committed to the Committee on Insurance
 
 AN ACT to amend the insurance law and the public health law, in relation
   to enhanced disclosure of step therapy override requests and  determi-
   nations; and to repeal certain provisions of such laws relating there-
   to

   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Section 4903 of the insurance law is amended by adding  two
 new subsections (j) and (k) to read as follows:
   (J) EACH HEALTH CARE PLAN AND UTILIZATION REVIEW AGENT SHALL ANNUALLY,
 IN  SUCH FORM AS THE SUPERINTENDENT SHALL REQUIRE, REPORT INFORMATION TO
 THE DEPARTMENT REGARDING STEP THERAPY  OVERRIDE  REQUESTS  AND  DETERMI-
 NATIONS. SUCH REPORTS SHALL, AMONG OTHER THINGS, SEPARATELY IDENTIFY THE
 FOLLOWING  INFORMATION, ORGANIZED BY INDIVIDUAL DRUG NAME AND DRUG CATE-
 GORY AND CLASS:
   (1)  THE  NUMBER  OF  STEP  THERAPY  OVERRIDE  DETERMINATION  REQUESTS
 RECEIVED;
   (2)  THE  TYPE  OF HEALTH CARE PROVIDERS OR THE MEDICAL SPECIALTIES OF
 THE HEALTH CARE PROVIDERS SUBMITTING REQUESTS;
   (3) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE INITIALLY DENIED AND THE REASONS FOR SUCH DENIALS;
   (4)  THE  NUMBER  OF STEP THERAPY OVERRIDE DETERMINATION REQUESTS THAT
 WERE INITIALLY APPROVED; AND
   (5) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE REVERSED ON INTERNAL APPEAL.
   (K) EACH HEALTH CARE PLAN AND UTILIZATION REVIEW AGENT SHALL DISCLOSE,
 IN  SUCH  FORM  AS  THE  SUPERINTENDENT  SHALL REQUIRE, NON-CONFIDENTIAL
 INFORMATION REGARDING STEP THERAPY OVERRIDE REQUESTS AND  DETERMINATIONS
 ON A WEBSITE OR WEB-BASED TOOL THAT IS READILY ACCESSIBLE TO THE PUBLIC.
 SUCH  DISCLOSURE  SHALL,  AMONG  OTHER  THINGS,  SEPARATELY IDENTIFY THE
 FOLLOWING INFORMATION, ORGANIZED BY INDIVIDUAL DRUG NAME AND DRUG  CATE-
 GORY AND CLASS:
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD14461-01-2

 S. 8798                             2
 
   (1)  THE  NUMBER  OF  STEP  THERAPY  OVERRIDE  DETERMINATION  REQUESTS
 RECEIVED;
   (2)  THE  TYPE  OF HEALTH CARE PROVIDERS OR THE MEDICAL SPECIALTIES OF
 THE HEALTH CARE PROVIDERS SUBMITTING REQUESTS;
   (3) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE INITIALLY DENIED AND THE REASONS FOR SUCH DENIALS;
   (4)  THE  NUMBER  OF STEP THERAPY OVERRIDE DETERMINATION REQUESTS THAT
 WERE INITIALLY APPROVED; AND
   (5) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE REVERSED ON INTERNAL APPEAL.
   §  2.  Section  4903 of the public health law is amended by adding two
 new subdivisions 10 and 11 to read as follows:
   10. EACH HEALTH CARE PLAN AND UTILIZATION REVIEW AGENT SHALL ANNUALLY,
 IN SUCH FORM AS THE COMMISSIONER SHALL REQUIRE,  REPORT  INFORMATION  TO
 THE  DEPARTMENT  REGARDING  STEP THERAPY OVERRIDE DETERMINATION REQUESTS
 AND THE OUTCOMES OF SUCH  REQUESTS.  SUCH  REPORTS  SHALL,  AMONG  OTHER
 THINGS,  SEPARATELY  IDENTIFY  THE  FOLLOWING  INFORMATION, ORGANIZED BY
 INDIVIDUAL DRUG NAME AND DRUG CATEGORY AND CLASS:
   (A)  THE  NUMBER  OF  STEP  THERAPY  OVERRIDE  DETERMINATION  REQUESTS
 RECEIVED;
   (B)  THE  TYPE  OF HEALTH CARE PROVIDERS OR THE MEDICAL SPECIALTIES OF
 THE HEALTH CARE PROVIDERS SUBMITTING REQUESTS;
   (C) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE INITIALLY DENIED AND THE REASONS FOR SUCH DENIALS;
   (D)  THE  NUMBER  OF STEP THERAPY OVERRIDE DETERMINATION REQUESTS THAT
 WERE INITIALLY APPROVED; AND
   (E) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE REVERSED ON INTERNAL APPEAL.
   11. EACH HEALTH CARE PLAN AND UTILIZATION REVIEW AGENT SHALL DISCLOSE,
 IN  SUCH FORM AS THE COMMISSIONER SHALL REQUIRE, NON-CONFIDENTIAL INFOR-
 MATION REGARDING STEP THERAPY OVERRIDE REQUESTS AND DETERMINATIONS ON  A
 WEBSITE  OR  WEB-BASED  TOOL  THAT  IS READILY ACCESSIBLE TO THE PUBLIC.
 SUCH DISCLOSURE SHALL,  AMONG  OTHER  THINGS,  SEPARATELY  IDENTIFY  THE
 FOLLOWING  INFORMATION, ORGANIZED BY INDIVIDUAL DRUG NAME AND DRUG CATE-
 GORY AND CLASS:
   (A)  THE  NUMBER  OF  STEP  THERAPY  OVERRIDE  DETERMINATION  REQUESTS
 RECEIVED;
   (B)  THE  TYPE  OF HEALTH CARE PROVIDERS OR THE MEDICAL SPECIALTIES OF
 THE HEALTH CARE PROVIDERS SUBMITTING REQUESTS;
   (C) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE INITIALLY DENIED AND THE REASONS FOR SUCH DENIALS;
   (D)  THE  NUMBER  OF STEP THERAPY OVERRIDE DETERMINATION REQUESTS THAT
 WERE INITIALLY APPROVED; AND
   (E) THE NUMBER OF STEP THERAPY OVERRIDE  DETERMINATION  REQUESTS  THAT
 WERE REVERSED ON INTERNAL APPEAL.
   § 3. Paragraph 10 of subsection (b) of section 3217-a of the insurance
 law  is REPEALED and three new subsections (g), (h) and (i) are added to
 read as follows:
   (G) WHERE APPLICABLE, EACH  INSURER  SUBJECT  TO  THIS  ARTICLE  SHALL
 DISCLOSE  INFORMATION  ON  STEP THERAPY PROTOCOLS, STEP THERAPY OVERRIDE
 DETERMINATIONS, AND INTERNAL AND EXTERNAL APPEALS, AS GOVERNED BY  ARTI-
 CLE  FORTY-NINE  OF  THIS  CHAPTER,  AND  ANY ASSOCIATED CLINICAL REVIEW
 CRITERIA PERTAINING TO SPECIFIC CONDITIONS AND DISEASES.  SUCH  INFORMA-
 TION  SHALL  BE MADE READILY ACCESSIBLE ON THE INSURER'S WEBSITE OR WEB-
 BASED TOOL AND, UPON REQUEST,  IN  WRITTEN  OR  ELECTRONIC  FORM  TO  AN
 INSURED  OR  AN  INSURED'S  AUTHORIZED  REPRESENTATIVE AND A HEALTH CARE
 S. 8798                             3
 
 PROFESSIONAL AS DEFINED IN SUBSECTION (F) OF SECTION FOUR THOUSAND  NINE
 HUNDRED OF THIS CHAPTER.
   (H)  IF AN INSURER SUBJECT TO THIS ARTICLE INTENDS EITHER TO IMPLEMENT
 A NEW REQUIREMENT OR RESTRICTION OR AMEND  AN  EXISTING  REQUIREMENT  OR
 RESTRICTION,  RELATING  TO A STEP THERAPY PROTOCOL, INTERNAL OR EXTERNAL
 STEP THERAPY APPEALS PROTOCOL, OR ASSOCIATED CLINICAL  REVIEW  CRITERIA,
 SUCH  INSURER  SHALL  ENSURE  THAT  SUCH  NEW  OR AMENDED REQUIREMENT OR
 RESTRICTION IS NOT IMPLEMENTED UNLESS SUCH  INSURER'S  WEBSITE  OR  WEB-
 BASED  TOOL  HAS BEEN UPDATED TO REFLECT SUCH NEW OR AMENDED REQUIREMENT
 OR RESTRICTION.
   (I) IF AN INSURER SUBJECT TO THIS ARTICLE INTENDS EITHER TO  IMPLEMENT
 A  NEW  REQUIREMENT  OR RESTRICTION, OR AMEND AN EXISTING REQUIREMENT OR
 RESTRICTION, RELATING TO A STEP THERAPY PROTOCOL, INTERNAL  OR  EXTERNAL
 STEP  THERAPY  APPEALS PROTOCOL, OR ASSOCIATED CLINICAL REVIEW CRITERIA,
 SUCH INSURER SHALL PROVIDE ANY INSURED OR HEALTH  CARE  PROFESSIONAL  AS
 DEFINED  IN SUBSECTION (F) OF SECTION FOUR THOUSAND NINE HUNDRED OF THIS
 CHAPTER WHO MAY BE IMPACTED BY SUCH  NEW  REQUIREMENT,  RESTRICTION,  OR
 AMENDMENT  WITH  WRITTEN NOTICE OF SUCH NEW REQUIREMENT, RESTRICTION, OR
 AMENDMENT NO LESS THAN SIXTY DAYS BEFORE IMPLEMENTATION. SUCH NOTICE MAY
 BE DELIVERED ELECTRONICALLY OR BY OTHER MEANS.
   § 4. Paragraph 10 of subsection (b) of section 4324 of  the  insurance
 law  is REPEALED and three new subsections (g), (h) and (i) are added to
 read as follows:
   (G) WHERE  APPLICABLE,  EACH  HEALTH  SERVICE,  HOSPITAL  SERVICE,  OR
 MEDICAL  INDEMNITY  CORPORATION  SUBJECT  TO THIS ARTICLE SHALL DISCLOSE
 INFORMATION ON STEP THERAPY PROTOCOLS, STEP  THERAPY  OVERRIDE  DETERMI-
 NATIONS,  AND  INTERNAL  AND  EXTERNAL  APPEALS,  AS GOVERNED BY ARTICLE
 FORTY-NINE OF THIS CHAPTER, AND ANY ASSOCIATED CLINICAL REVIEW  CRITERIA
 PERTAINING  TO  SPECIFIC CONDITIONS AND DISEASES. SUCH INFORMATION SHALL
 BE MADE READILY ACCESSIBLE ON SUCH HEALTH SERVICE, HOSPITAL SERVICE,  OR
 MEDICAL  INDEMNITY  CORPORATION'S  WEBSITE  OR  WEB-BASED TOOL AND, UPON
 REQUEST, IN WRITTEN OR ELECTRONIC FORM TO AN INSURED  OR  THE  INSURED'S
 AUTHORIZED  REPRESENTATIVE  AND A HEALTH CARE PROFESSIONAL AS DEFINED IN
 SUBSECTION (F) OF SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER.
   (H) IF A HEALTH SERVICE, HOSPITAL SERVICE, OR MEDICAL INDEMNITY CORPO-
 RATION SUBJECT TO  THIS  ARTICLE  INTENDS  EITHER  TO  IMPLEMENT  A  NEW
 REQUIREMENT   OR   RESTRICTION  OR  AMEND  AN  EXISTING  REQUIREMENT  OR
 RESTRICTION, RELATING TO A STEP THERAPY PROTOCOL, INTERNAL  OR  EXTERNAL
 STEP  THERAPY  APPEALS PROTOCOL, OR ASSOCIATED CLINICAL REVIEW CRITERIA,
 SUCH HEALTH SERVICE, HOSPITAL SERVICE, OR MEDICAL INDEMNITY  CORPORATION
 SHALL  ENSURE THAT SUCH NEW OR AMENDED REQUIREMENT OR RESTRICTION IS NOT
 IMPLEMENTED UNLESS SUCH HEALTH SERVICE,  HOSPITAL  SERVICE,  OR  MEDICAL
 INDEMNITY  CORPORATION'S  WEBSITE  OR WEB-BASED TOOL HAS BEEN UPDATED TO
 REFLECT SUCH NEW OR AMENDED REQUIREMENT OR RESTRICTION.
   (I) IF A HEALTH SERVICE, HOSPITAL SERVICE, OR MEDICAL INDEMNITY CORPO-
 RATION SUBJECT TO  THIS  ARTICLE  INTENDS  EITHER  TO  IMPLEMENT  A  NEW
 REQUIREMENT   OR   RESTRICTION  OR  AMEND  AN  EXISTING  REQUIREMENT  OR
 RESTRICTION, RELATING TO A STEP THERAPY PROTOCOL, INTERNAL  OR  EXTERNAL
 STEP  THERAPY  APPEALS PROTOCOL, OR ASSOCIATED CLINICAL REVIEW CRITERIA,
 SUCH HEALTH SERVICE, HOSPITAL SERVICE, OR MEDICAL INDEMNITY  CORPORATION
 SHALL  PROVIDE  ANY  INSURED  OR  HEALTH CARE PROFESSIONAL AS DEFINED IN
 SUBSECTION (F) OF SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER WHO
 MAY BE IMPACTED BY SUCH NEW REQUIREMENT, RESTRICTION, OR AMENDMENT  WITH
 WRITTEN  NOTICE  OF  SUCH  NEW REQUIREMENT, RESTRICTION, OR AMENDMENT NO
 LESS THAN SIXTY DAYS BEFORE IMPLEMENTATION. SUCH NOTICE MAY BE DELIVERED
 ELECTRONICALLY OR BY OTHER MEANS.
 S. 8798                             4
 
   § 5. Paragraph (j) of subdivision 2 of  section  4408  of  the  public
 health  law  is  REPEALED and three new subdivisions 8, 9 and 10 and are
 added to read as follows:
   8.  WHERE  APPLICABLE, EACH HEALTH MAINTENANCE ORGANIZATION SUBJECT TO
 THIS ARTICLE SHALL DISCLOSE INFORMATION ON STEP THERAPY PROTOCOLS,  STEP
 THERAPY  OVERRIDE  DETERMINATIONS, AND INTERNAL AND EXTERNAL APPEALS, AS
 GOVERNED BY ARTICLE FORTY-NINE OF THIS CHAPTER, AND ANY ASSOCIATED CLIN-
 ICAL REVIEW CRITERIA PERTAINING TO  SPECIFIC  CONDITIONS  AND  DISEASES.
 SUCH INFORMATION SHALL BE MADE READILY ACCESSIBLE ON SUCH HEALTH MAINTE-
 NANCE  ORGANIZATION'S  WEBSITE  OR  WEB-BASED TOOL AND, UPON REQUEST, IN
 WRITTEN OR ELECTRONIC FORM TO AN ENROLLEE OR THE  ENROLLEE'S  AUTHORIZED
 REPRESENTATIVE  AND  A HEALTH CARE PROFESSIONAL AS DEFINED IN SUBSECTION
 (F) OF SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER.
   9. IF A  HEALTH  MAINTENANCE  ORGANIZATION  SUBJECT  TO  THIS  ARTICLE
 INTENDS EITHER TO IMPLEMENT A NEW REQUIREMENT OR RESTRICTION OR AMEND AN
 EXISTING  REQUIREMENT  OR RESTRICTION, RELATING TO A STEP THERAPY PROTO-
 COL, INTERNAL OR EXTERNAL STEP THERAPY APPEALS PROTOCOL,  OR  ASSOCIATED
 CLINICAL  REVIEW  CRITERIA,  SUCH  HEALTH MAINTENANCE ORGANIZATION SHALL
 ENSURE THAT SUCH NEW OR AMENDED REQUIREMENT OR RESTRICTION IS NOT IMPLE-
 MENTED UNLESS SUCH HEALTH MAINTENANCE  ORGANIZATION'S  WEBSITE  OR  WEB-
 BASED  TOOL  HAS BEEN UPDATED TO REFLECT SUCH NEW OR AMENDED REQUIREMENT
 OR RESTRICTION.
   10. IF A HEALTH  MAINTENANCE  ORGANIZATION  SUBJECT  TO  THIS  ARTICLE
 INTENDS EITHER TO IMPLEMENT A NEW REQUIREMENT OR RESTRICTION OR AMEND AN
 EXISTING  REQUIREMENT  OR RESTRICTION, RELATING TO A STEP THERAPY PROTO-
 COL, INTERNAL OR EXTERNAL STEP THERAPY APPEALS PROTOCOL,  OR  ASSOCIATED
 CLINICAL  REVIEW  CRITERIA,  SUCH  HEALTH MAINTENANCE ORGANIZATION SHALL
 PROVIDE  ANY  ENROLLEE  OR  HEALTH  CARE  PROFESSIONAL  AS  DEFINED   IN
 SUBSECTION (F) OF SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER WHO
 MAY  BE IMPACTED BY SUCH NEW REQUIREMENT, RESTRICTION, OR AMENDMENT WITH
 WRITTEN NOTICE OF SUCH NEW REQUIREMENT,  RESTRICTION,  OR  AMENDMENT  NO
 LESS THAN SIXTY DAYS BEFORE IMPLEMENTATION. SUCH NOTICE MAY BE DELIVERED
 ELECTRONICALLY OR BY OTHER MEANS.
   § 6. This act shall take effect immediately.

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Senate Bill S8798

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Sponsored By

Neil D. Breslin