S T A T E O F N E W Y O R K
________________________________________________________________________
1350
2023-2024 Regular Sessions
I N S E N A T E
January 11, 2023
___________
Introduced by Sen. RIVERA -- read twice and ordered printed, and when
printed to be committed to the Committee on Rules
AN ACT to amend the insurance law, in relation to calculating an insured
individual's overall contribution to any out-of-pocket maximum or any
cost-sharing requirement; and to amend a chapter of the laws of 2022
amending the insurance law relating to calculating an insured individ-
ual's overall contribution to any out-of-pocket maximum or any cost-
sharing requirement, as proposed in legislative bills numbers S.
5299-A and A. 1741-A, in relation to the effectiveness thereof
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Paragraph 37 of subsection (i) of section 3216 of the
insurance law, as added by a chapter of the laws of 2022 amending the
insurance law relating to calculating an insured individual's overall
contribution to any out-of-pocket maximum or any cost-sharing require-
ment, as proposed in legislative bills numbers S. 5299-A and A. 1741-A,
is amended to read as follows:
(37) Any policy that provides coverage for prescription drugs shall
apply any third-party payments, financial assistance, discount, voucher
or other price reduction instrument for out-of-pocket expenses made on
behalf of an insured individual for the cost of A prescription [drugs]
DRUG to the insured's deductible, copayment, coinsurance, out-of-pocket
maximum, or any other cost-sharing requirement when calculating such
insured individual's overall contribution to any out-of-pocket maximum
or any cost-sharing requirement. If under federal law, application of
this requirement would result in health savings account ineligibility
under 26 USC 223, this requirement shall apply for health savings
account-qualified high deductible health plans with respect to the
deductible of such a plan after the enrollee has satisfied the minimum
deductible under 26 USC 223, except for with respect to items or
services that are preventive care pursuant to 26 USC 223(c)(2)(C), in
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD04217-01-3
S. 1350 2
which case the requirements of this paragraph shall apply regardless of
whether the minimum deductible under 26 USC 223 has been satisfied.
THIS PARAGRAPH ONLY APPLIES TO A PRESCRIPTION DRUG THAT IS EITHER (A) A
BRAND-NAME DRUG WITHOUT AN AB RATED GENERIC EQUIVALENT, AS DETERMINED BY
THE UNITED STATES FOOD AND DRUG ADMINISTRATION; OR (B) A BRAND-NAME DRUG
WITH AN AB RATED GENERIC EQUIVALENT, AS DETERMINED BY THE UNITED STATES
FOOD AND DRUG ADMINISTRATION, AND THE INSURED HAS ACCESS TO THE BRAND-
NAME DRUG THROUGH PRIOR AUTHORIZATION BY THE INSURER OR THROUGH THE
INSURER'S APPEAL PROCESS, INCLUDING ANY STEP-THERAPY PROCESS; OR (C) A
GENERIC DRUG THE INSURER WILL COVER, WITH OR WITHOUT PRIOR AUTHORIZATION
OR AN APPEAL PROCESS.
§ 2. Paragraph 21 of subsection (l) of section 3221 of the insurance
law, as added by a chapter of the laws of 2022 amending the insurance
law relating to calculating an insured individual's overall contribution
to any out-of-pocket maximum or any cost-sharing requirement, as
proposed in legislative bills numbers S. 5299-A and A. 1741-A, is
amended to read as follows:
(21) Every group or blanket policy delivered or issued for delivery in
this state that provides coverage for A prescription [drugs] DRUG shall
apply any third-party payments, financial assistance, discount, voucher
or other price reduction instrument for out-of-pocket expenses made on
behalf of an insured individual for the cost of prescription drugs to
the insured's deductible, copayment, coinsurance, out-of-pocket maximum,
or any other cost-sharing requirement when calculating such insured
individual's overall contribution to any out-of-pocket maximum or any
cost-sharing requirement. If under federal law, application of this
requirement would result in health savings account ineligibility under
26 USC 223, this requirement shall apply for health savings account-qua-
lified high deductible health plans with respect to the deductible of
such a plan after the enrollee has satisfied the minimum deductible
under 26 USC 223, except for with respect to items or services that are
preventive care pursuant to 26 USC 223(c)(2)(C), in which case the
requirements of this paragraph shall apply regardless of whether the
minimum deductible under 26 USC 223 has been satisfied. THIS PARAGRAPH
ONLY APPLIES TO A PRESCRIPTION DRUG THAT IS EITHER (A) A BRAND-NAME DRUG
WITHOUT AN AB RATED GENERIC EQUIVALENT, AS DETERMINED BY THE UNITED
STATES FOOD AND DRUG ADMINISTRATION; OR (B) A BRAND-NAME DRUG WITH AN AB
RATED GENERIC EQUIVALENT, AS DETERMINED BY THE UNITED STATES FOOD AND
DRUG ADMINISTRATION, AND THE INSURED HAS ACCESS TO THE BRAND-NAME DRUG
THROUGH PRIOR AUTHORIZATION BY THE INSURER OR THROUGH THE INSURER'S
APPEAL PROCESS, INCLUDING ANY STEP-THERAPY PROCESS; OR (C) A GENERIC
DRUG THE INSURER WILL COVER, WITH OR WITHOUT PRIOR AUTHORIZATION OR AN
APPEAL PROCESS.
§ 3. Subsection (tt) of section 4303 of the insurance law, as added by
a chapter of the laws of 2022 amending the insurance law relating to
calculating an insured individual's overall contribution to any out-of-
pocket maximum or any cost-sharing requirement, as proposed in legisla-
tive bills numbers S. 5299-A and A. 1741-A, is amended to read as
follows:
(tt) Every contract issued by a medical expense indemnity corporation,
hospital service corporation, or health service corporation that
provides coverage for A prescription [drugs] DRUG shall apply any third-
party payments, financial assistance, discount, voucher or other price
reduction instrument for out-of-pocket expenses made on behalf of an
insured individual for the cost of prescription drugs to the insured's
deductible, copayment, coinsurance, out-of-pocket maximum, or any other
S. 1350 3
cost-sharing requirement when calculating such insured individual's
overall contribution to any out-of-pocket maximum or any cost-sharing
requirement. If under federal law, application of this requirement would
result in health savings account ineligibility under 26 USC 223, this
requirement shall apply for health savings account-qualified high deduc-
tible health plans with respect to the deductible of such a plan after
the enrollee has satisfied the minimum deductible under 26 USC 223,
except for with respect to items or services that are preventive care
pursuant to 26 USC 223(c)(2)(C), in which case the requirements of this
paragraph shall apply regardless of whether the minimum deductible under
26 USC 223 has been satisfied. THIS SUBSECTION ONLY APPLIES TO A
PRESCRIPTION DRUG THAT IS EITHER (A) A BRAND-NAME DRUG WITHOUT AN AB
RATED GENERIC EQUIVALENT, AS DETERMINED BY THE UNITED STATES FOOD AND
DRUG ADMINISTRATION; OR (B) A BRAND-NAME DRUG WITH AN AB RATED GENERIC
EQUIVALENT, AS DETERMINED BY THE UNITED STATES FOOD AND DRUG ADMINIS-
TRATION, AND THE INSURED HAS ACCESS TO THE BRAND-NAME DRUG THROUGH PRIOR
AUTHORIZATION BY THE INSURER OR THROUGH THE INSURER'S APPEAL PROCESS,
INCLUDING ANY STEP-THERAPY PROCESS; OR (C) A GENERIC DRUG THE INSURER
WILL COVER, WITH OR WITHOUT PRIOR AUTHORIZATION OR AN APPEAL PROCESS.
§ 4. Section 4 of a chapter of the laws of 2022 amending the insur-
ance law relating to calculating an insured individual's overall
contribution to any out-of-pocket maximum or any cost-sharing require-
ment, as proposed in legislative bills numbers S. 5299-A and A. 1741-A,
is amended to read as follows:
§ 4. This act shall take effect on the first of [January] JULY next
succeeding the date on which it shall have become a law and shall apply
to all policies and contracts issued, renewed, modified, altered or
amended on or after such date.
§ 5. This act shall take effect immediately; provided, however, that
sections one, two and three of this act shall take effect on the same
date and in the same manner as a chapter of the laws of 2022 amending
the insurance law relating to calculating an insured individual's over-
all contribution to any out-of-pocket maximum or any cost-sharing
requirement, as proposed in legislative bills numbers S. 5299-A and A.
1741-A, takes effect.