S T A T E O F N E W Y O R K
________________________________________________________________________
1384
2023-2024 Regular Sessions
I N A S S E M B L Y
January 17, 2023
___________
Introduced by M. of A. McDONALD, STECK -- read once and referred 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
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD04045-01-3
A. 1384 2
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.
§ 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-
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BASED TOOL AND, UPON REQUEST, IN WRITTEN OR ELECTRONIC FORM TO AN
INSURED OR AN 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 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
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LESS THAN SIXTY DAYS BEFORE IMPLEMENTATION. SUCH NOTICE MAY BE DELIVERED
ELECTRONICALLY OR BY OTHER MEANS.
§ 5. Paragraph (j) of subdivision 2 of section 4408 of the public
health law is REPEALED and three new subdivisions 9, 10 and 11 are added
to read as follows:
9. 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 SUBDIVISION
SIX OF SECTION FORTY-NINE HUNDRED OF THIS CHAPTER.
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
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.
11. 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 SUBDIVI-
SION SIX OF SECTION FORTY-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 ELECTRON-
ICALLY OR BY OTHER MEANS.
§ 6. This act shall take effect immediately.