S T A T E O F N E W Y O R K
________________________________________________________________________
463--A
2023-2024 Regular Sessions
I N A S S E M B L Y
January 9, 2023
___________
Introduced by M. of A. McDONALD, STECK, GUNTHER, STIRPE, K. BROWN,
WEPRIN, COLTON, BENDETT -- read once and referred to the Committee on
Insurance -- reported and referred to the Committee on Rules -- Rules
Committee discharged, bill amended, ordered reprinted as amended and
recommitted to the Committee on Rules
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:
Section 1. Subsection (a) of section 4902 of the insurance law is
amended by adding a new paragraph 14 to read as follows:
(14) ESTABLISHMENT OF A WRITTEN PROCEDURE TO ASSURE THAT THE NOTICE OF
AN ADVERSE DETERMINATION IN RELATION TO A STEP THERAPY PROTOCOL OVERRIDE
DETERMINATION REQUEST INCLUDES:
(I) THE REASONS FOR THE DETERMINATION INCLUDING THE CLINICAL RATION-
ALE, IF ANY;
(II) INSTRUCTIONS ON HOW TO INITIATE STANDARD AND EXPEDITED APPEALS
PURSUANT TO SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE AND
AN EXTERNAL APPEAL PURSUANT TO SECTION FOUR THOUSAND NINE HUNDRED FOUR-
TEEN OF THIS ARTICLE;
(III) INFORMATION THAT INCLUDES: ANY APPLICABLE ALTERNATIVE COVERED
MEDICATIONS; THE CLINICAL REVIEW CRITERIA RELIED UPON TO MAKE SUCH
DETERMINATION; AND ANY ADDITIONAL NECESSARY INFORMATION THAT MUST BE
PROVIDED TO, OR OBTAINED BY, THE UTILIZATION REVIEW AGENT IN ORDER TO
RENDER A DECISION ON THE APPEAL;
(IV) THE PROVISIONS OF THIS SECTION SHALL BE SATISFIED BY MAKING SUCH
INFORMATION AVAILABLE ELECTRONICALLY ON A FORMULARY WEBSITE, ON THE
MEMBER PORTAL AND/OR PROVIDER PORTAL OF THE INSURER'S, THE HEALTH MAIN-
TENANCE ORGANIZATION'S WEBSITE, OR THE WEBSITE OF AN ORGANIZATION
SUBJECT TO ARTICLE FORTY-THREE OF THIS CHAPTER, PROVIDED THAT THE MEMBER
CONSENTS TO RECEIVING THE INFORMATION ELECTRONICALLY.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02500-03-3
A. 463--A 2
§ 2. Section 4903 of the insurance law is amended by adding a new
subsection (e-1) to read as follows:
(E-1) NOTICE OF AN ADVERSE DETERMINATION MADE BY A UTILIZATION REVIEW
AGENT IN RELATION TO A STEP THERAPY PROTOCOL OVERRIDE DETERMINATION
REQUEST SHALL BE MADE IN WRITING TO THE INSURED OR THE INSURED'S AUTHOR-
IZED REPRESENTATIVE AND THE INSURED'S PRESCRIBING HEALTH CARE PROFES-
SIONAL AS DEFINED IN SUBSECTION (F) OF SECTION FORTY-NINE HUNDRED OF
THIS CHAPTER, AND SHALL INCLUDE:
(I) THE REASONS FOR THE DETERMINATION INCLUDING THE CLINICAL RATION-
ALE, IF ANY;
(II) INSTRUCTIONS ON HOW TO INITIATE STANDARD AND EXPEDITED APPEALS
PURSUANT TO SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE AND
AN EXTERNAL APPEAL PURSUANT TO SECTION FOUR THOUSAND NINE HUNDRED FOUR-
TEEN OF THIS ARTICLE;
(III) INFORMATION THAT INCLUDES: ANY APPLICABLE ALTERNATIVE COVERED
MEDICATIONS; THE CLINICAL REVIEW CRITERIA RELIED UPON TO MAKE SUCH
DETERMINATION; AND ANY ADDITIONAL NECESSARY INFORMATION THAT MUST BE
PROVIDED TO, OR OBTAINED BY, THE UTILIZATION REVIEW AGENT IN ORDER TO
RENDER A DECISION ON THE APPEAL;
(IV) THE PROVISIONS OF THIS SECTION SHALL BE SATISFIED BY MAKING SUCH
INFORMATION AVAILABLE ELECTRONICALLY ON A FORMULARY WEBSITE, ON THE
MEMBER PORTAL AND/OR PROVIDER PORTAL OF THE INSURER'S, THE HEALTH MAIN-
TENANCE ORGANIZATION'S WEBSITE, OR THE WEBSITE OF AN ORGANIZATION
SUBJECT TO ARTICLE FORTY-THREE OF THIS CHAPTER, PROVIDED THAT THE MEMBER
CONSENTS TO RECEIVING THE INFORMATION ELECTRONICALLY.
§ 3. Subdivision 1 of section 4902 of the public health law is amended
by adding a new paragraph (l) to read as follows:
(L) ESTABLISHMENT OF A WRITTEN PROCEDURE TO ASSURE THAT THE NOTICE OF
AN ADVERSE DETERMINATION IN RELATION TO A STEP THERAPY PROTOCOL OVERRIDE
DETERMINATION REQUEST INCLUDES: (I) THE REASONS FOR THE DETERMINATION
INCLUDING THE CLINICAL RATIONALE, IF ANY; (II) INSTRUCTIONS ON HOW TO
INITIATE STANDARD AND EXPEDITED APPEALS PURSUANT TO SUBDIVISION TWO OF
SECTION FORTY-NINE HUNDRED FOUR OF THIS TITLE AND AN EXTERNAL APPEAL
PURSUANT TO SECTION FORTY-NINE HUNDRED FOURTEEN OF THIS ARTICLE; (III)
INFORMATION THAT INCLUDES: ANY APPLICABLE ALTERNATIVE COVERED MEDICA-
TIONS; THE CLINICAL REVIEW CRITERIA RELIED UPON TO MAKE SUCH DETERMI-
NATION; AND ANY ADDITIONAL NECESSARY INFORMATION THAT MUST BE PROVIDED
TO, OR OBTAINED BY, THE UTILIZATION REVIEW AGENT IN ORDER TO RENDER A
DECISION ON THE APPEAL; (IV) THE PROVISIONS OF THIS SECTION SHALL BE
SATISFIED BY MAKING SUCH INFORMATION AVAILABLE ELECTRONICALLY ON A
FORMULARY WEBSITE, ON THE MEMBER PORTAL AND/OR PROVIDER PORTAL OF THE
INSURER'S, THE HEALTH MAINTENANCE ORGANIZATION'S WEBSITE, OR THE WEBSITE
OF AN ORGANIZATION SUBJECT TO ARTICLE FORTY-THREE OF THIS CHAPTER,
PROVIDED THAT THE MEMBER CONSENTS TO RECEIVING THE INFORMATION ELECTRON-
ICALLY.
§ 4. Section 4903 of the public health law is amended by adding a new
subdivision 5-a to read as follows:
5-A. NOTICE OF AN ADVERSE DETERMINATION MADE BY A UTILIZATION REVIEW
AGENT IN RELATION TO A STEP THERAPY PROTOCOL OVERRIDE DETERMINATION
REQUEST SHALL BE MADE IN WRITING TO THE ENROLLEE OR THE ENROLLEE'S
AUTHORIZED REPRESENTATIVE AND THE ENROLLEE'S PRESCRIBING HEALTH CARE
PROFESSIONAL AS DEFINED IN SUBDIVISION SIX OF SECTION FORTY-NINE HUNDRED
OF THIS TITLE, AND SHALL INCLUDE:
(A) THE REASONS FOR THE DETERMINATION INCLUDING THE CLINICAL RATION-
ALE, IF ANY;
A. 463--A 3
(B) INSTRUCTIONS ON HOW TO INITIATE STANDARD AND EXPEDITED APPEALS
PURSUANT TO SECTION FORTY-NINE HUNDRED FOUR OF THIS TITLE AND AN
EXTERNAL APPEAL PURSUANT TO SECTION FORTY-NINE HUNDRED FOURTEEN OF THIS
ARTICLE;
(C) INFORMATION THAT INCLUDES: ANY APPLICABLE ALTERNATIVE COVERED
MEDICATIONS; THE CLINICAL REVIEW CRITERIA RELIED UPON TO MAKE SUCH
DETERMINATION; AND ANY ADDITIONAL NECESSARY INFORMATION THAT MUST BE
PROVIDED TO, OR OBTAINED BY, THE UTILIZATION REVIEW AGENT IN ORDER TO
RENDER A DECISION ON THE APPEAL;
(D) THE PROVISIONS OF THIS SECTION SHALL BE SATISFIED BY MAKING SUCH
INFORMATION AVAILABLE ELECTRONICALLY ON A FORMULARY WEBSITE, ON THE
MEMBER PORTAL AND/OR PROVIDER PORTAL OF THE INSURER'S, THE HEALTH MAIN-
TENANCE ORGANIZATION'S WEBSITE, OR THE WEBSITE OF AN ORGANIZATION
SUBJECT TO ARTICLE FORTY-THREE OF THIS CHAPTER, PROVIDED THAT THE MEMBER
CONSENTS TO RECEIVING THE INFORMATION ELECTRONICALLY.
§ 5. This act shall take effect on the ninetieth day after it shall
have become a law. Effective immediately, the addition, amendment and/or
repeal of any rule or regulation necessary for the implementation of
this act on its effective date are authorized to be made and completed
on or before such effective date.