Assembly Bill A9265

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   9265
 
                           I N  A S S E M B L Y
 
                             February 9, 2022
                                ___________
 
 Introduced by M. of A. McDONALD -- read once and referred to the Commit-
   tee on Insurance
 
 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.
   §  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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD14434-01-2
 A. 9265                             2
 
 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.
   § 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.
   §  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;
   (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.
   § 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.