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.