Steck, Stirpe, Brown K, Colton, Bendett, Gunther, Paulin, Lavine, Lunsford
MLTSPNSR
Amd §§4903 & 4408, rpld §4408 sub 2 ¶(j), Pub Health L; rpld §3217-a sub§ (b) ¶10, §4324 sub§ (b) ¶10, amd
§§3217-a, 4903 & 4324, Ins L
Requires disclosure, in such form as the superintendent shall require, of non-confidential information regarding step therapy override requests and determinations on a website that is readily accessible to the public.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A1384
SPONSOR: McDonald TITLE OF BILL:
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 thereto
PURPOSE OR GENERAL IDEA OF BILL:
The purpose of this bill is to require insurers and utilization review
agents to report to the Department of Financial Services (DFS) and
require insurers and certain health organizations to make publicly
available certain information on step therapy override requests,
appeals, and their outcomes.
SUMMARY OF PROVISIONS:
Section one amends section 4903 of the insurance law to require each
health care plan and utilization review agents to annually report infor-
mation to DFS regarding step therapy override requests and determi-
nations. The report must include, but is not limited to, the number of
step therapy override determination requests. In addition, the report
must include the type of health care providers submitting requests. The
report must include the number of step therapy override determination
requests that were initially denied and the reasons for such denials.
The report must include the number of step therapy override determi-
nation requests that were initially approved and the number of requests
that were reversed upon appeal.
The utilization review agent is also required to disclose the same non-
confidential information, listed above, in a form the Superintendent
requires and must post on a readily accessible website.
Section two amends section 4903 of the public health law with the same
requirements as section one.
Section three repeals section 3217-a of the insurance law and adds three
new subsections. New subsection (g) requires each insurer subject to
this article to disclose information on step therapy protocols, step
therapy override determinations, internal and external appeals, and
associated clinical review information on a publicly accessible website
and upon request in written or electronic form. Subsection (h) requires
such insurers to update their websites with information related to any
new requirement or restrictions before implementation. Finally,
subsection (i) requires such insurers to provide any insured or health
care professional who may be impacted by any new requirements,
restrictions, or amendments with written notice no less than 60 days
before implementation.
Section four repeals subsection (b) of section 4324 of the insurance law
and adds three new subsections similar to the amendments from section
three. These disclosure requirements apply to each health service,
hospital service, or medical indemnity corporation subject to this arti-
cle.
Section five repeals subdivision two of section 4408 of the public
health law and adds three new subdivisions similar to the amendments
made in sections three and four of this bill. These disclosure require-
ments apply to each health maintenance organization subject to this
article.
Section six requires that this act shall take effect immediately.
JUSTIFICATION:
Reporting requirements are essential to understand whether insurers are
complying with the law. It also allows patients and providers equal
access to information. Publication of step therapy data also provides
the patients, health care professionals, and policymakers the opportu-
nity to identify potential violations of the law and room for improve-
ment.
PRIOR LEGISLATIVE HISTORY:
2021-2022: A.9206
FISCAL IMPLICATIONS:
None
EFFECTIVE DATE:
This act shall take effect immediately.
STATE OF NEW YORK
________________________________________________________________________
1384
2023-2024 Regular Sessions
IN ASSEMBLY
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:
1 Section 1. Section 4903 of the insurance law is amended by adding two
2 new subsections (j) and (k) to read as follows:
3 (j) Each health care plan and utilization review agent shall annually,
4 in such form as the superintendent shall require, report information to
5 the department regarding step therapy override requests and determi-
6 nations. Such reports shall, among other things, separately identify the
7 following information, organized by individual drug name and drug cate-
8 gory and class:
9 (1) The number of step therapy override determination requests
10 received;
11 (2) The type of health care providers or the medical specialties of
12 the health care providers submitting requests;
13 (3) The number of step therapy override determination requests that
14 were initially denied and the reasons for such denials;
15 (4) The number of step therapy override determination requests that
16 were initially approved; and
17 (5) The number of step therapy override determination requests that
18 were reversed on internal appeal.
19 (k) Each health care plan and utilization review agent shall disclose,
20 in such form as the superintendent shall require, non-confidential
21 information regarding step therapy override requests and determinations
22 on a website or web-based tool that is readily accessible to the public.
23 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
1 following information, organized by individual drug name and drug cate-
2 gory and class:
3 (1) The number of step therapy override determination requests
4 received;
5 (2) The type of health care providers or the medical specialties of
6 the health care providers submitting requests;
7 (3) The number of step therapy override determination requests that
8 were initially denied and the reasons for such denials;
9 (4) The number of step therapy override determination requests that
10 were initially approved; and
11 (5) The number of step therapy override determination requests that
12 were reversed on internal appeal.
13 § 2. Section 4903 of the public health law is amended by adding two
14 new subdivisions 10 and 11 to read as follows:
15 10. Each health care plan and utilization review agent shall annually,
16 in such form as the commissioner shall require, report information to
17 the department regarding step therapy override determination requests
18 and the outcomes of such requests. Such reports shall, among other
19 things, separately identify the following information, organized by
20 individual drug name and drug category and class:
21 (a) The number of step therapy override determination requests
22 received;
23 (b) The type of health care providers or the medical specialties of
24 the health care providers submitting requests;
25 (c) The number of step therapy override determination requests that
26 were initially denied and the reasons for such denials;
27 (d) The number of step therapy override determination requests that
28 were initially approved; and
29 (e) The number of step therapy override determination requests that
30 were reversed on internal appeal.
31 11. Each health care plan and utilization review agent shall disclose,
32 in such form as the commissioner shall require, non-confidential infor-
33 mation regarding step therapy override requests and determinations on a
34 website or web-based tool that is readily accessible to the public.
35 Such disclosure shall, among other things, separately identify the
36 following information, organized by individual drug name and drug cate-
37 gory and class:
38 (a) The number of step therapy override determination requests
39 received;
40 (b) The type of health care providers or the medical specialties of
41 the health care providers submitting requests;
42 (c) The number of step therapy override determination requests that
43 were initially denied and the reasons for such denials;
44 (d) The number of step therapy override determination requests that
45 were initially approved; and
46 (e) The number of step therapy override determination requests that
47 were reversed on internal appeal.
48 § 3. Paragraph 10 of subsection (b) of section 3217-a of the insurance
49 law is REPEALED and three new subsections (g), (h) and (i) are added to
50 read as follows:
51 (g) Where applicable, each insurer subject to this article shall
52 disclose information on step therapy protocols, step therapy override
53 determinations, and internal and external appeals, as governed by arti-
54 cle forty-nine of this chapter, and any associated clinical review
55 criteria pertaining to specific conditions and diseases. Such informa-
56 tion shall be made readily accessible on the insurer's website or web-
A. 1384 3
1 based tool and, upon request, in written or electronic form to an
2 insured or an insured's authorized representative and a health care
3 professional as defined in subsection (f) of section four thousand nine
4 hundred of this chapter.
5 (h) If an insurer subject to this article intends either to implement
6 a new requirement or restriction or amend an existing requirement or
7 restriction, relating to a step therapy protocol, internal or external
8 step therapy appeals protocol, or associated clinical review criteria,
9 such insurer shall ensure that such new or amended requirement or
10 restriction is not implemented unless such insurer's website or web-
11 based tool has been updated to reflect such new or amended requirement
12 or restriction.
13 (i) If an insurer subject to this article intends either to implement
14 a new requirement or restriction, or amend an existing requirement or
15 restriction, relating to a step therapy protocol, internal or external
16 step therapy appeals protocol, or associated clinical review criteria,
17 such insurer shall provide any insured or health care professional as
18 defined in subsection (f) of section four thousand nine hundred of this
19 chapter who may be impacted by such new requirement, restriction, or
20 amendment with written notice of such new requirement, restriction, or
21 amendment no less than sixty days before implementation. Such notice may
22 be delivered electronically or by other means.
23 § 4. Paragraph 10 of subsection (b) of section 4324 of the insurance
24 law is REPEALED and three new subsections (g), (h) and (i) are added to
25 read as follows:
26 (g) Where applicable, each health service, hospital service, or
27 medical indemnity corporation subject to this article shall disclose
28 information on step therapy protocols, step therapy override determi-
29 nations, and internal and external appeals, as governed by article
30 forty-nine of this chapter, and any associated clinical review criteria
31 pertaining to specific conditions and diseases. Such information shall
32 be made readily accessible on such health service, hospital service, or
33 medical indemnity corporation's website or web-based tool and, upon
34 request, in written or electronic form to an insured or the insured's
35 authorized representative and a health care professional as defined in
36 subsection (f) of section four thousand nine hundred of this chapter.
37 (h) If a health service, hospital service, or medical indemnity corpo-
38 ration subject to this article intends either to implement a new
39 requirement or restriction or amend an existing requirement or
40 restriction, relating to a step therapy protocol, internal or external
41 step therapy appeals protocol, or associated clinical review criteria,
42 such health service, hospital service, or medical indemnity corporation
43 shall ensure that such new or amended requirement or restriction is not
44 implemented unless such health service, hospital service, or medical
45 indemnity corporation's website or web-based tool has been updated to
46 reflect such new or amended requirement or restriction.
47 (i) If a health service, hospital service, or medical indemnity corpo-
48 ration subject to this article intends either to implement a new
49 requirement or restriction or amend an existing requirement or
50 restriction, relating to a step therapy protocol, internal or external
51 step therapy appeals protocol, or associated clinical review criteria,
52 such health service, hospital service, or medical indemnity corporation
53 shall provide any insured or health care professional as defined in
54 subsection (f) of section four thousand nine hundred of this chapter who
55 may be impacted by such new requirement, restriction, or amendment with
56 written notice of such new requirement, restriction, or amendment no
A. 1384 4
1 less than sixty days before implementation. Such notice may be delivered
2 electronically or by other means.
3 § 5. Paragraph (j) of subdivision 2 of section 4408 of the public
4 health law is REPEALED and three new subdivisions 9, 10 and 11 are added
5 to read as follows:
6 9. Where applicable, each health maintenance organization subject to
7 this article shall disclose information on step therapy protocols, step
8 therapy override determinations, and internal and external appeals, as
9 governed by article forty-nine of this chapter, and any associated clin-
10 ical review criteria pertaining to specific conditions and diseases.
11 Such information shall be made readily accessible on such health mainte-
12 nance organization's website or web-based tool and, upon request, in
13 written or electronic form to an enrollee or the enrollee's authorized
14 representative and a health care professional as defined in subdivision
15 six of section forty-nine hundred of this chapter.
16 10. If a health maintenance organization subject to this article
17 intends either to implement a new requirement or restriction or amend an
18 existing requirement or restriction, relating to a step therapy proto-
19 col, internal or external step therapy appeals protocol, or associated
20 clinical review criteria, such health maintenance organization shall
21 ensure that such new or amended requirement or restriction is not imple-
22 mented unless such health maintenance organization's website or web-
23 based tool has been updated to reflect such new or amended requirement
24 or restriction.
25 11. If a health maintenance organization subject to this article
26 intends either to implement a new requirement or restriction or amend an
27 existing requirement or restriction, relating to a step therapy proto-
28 col, internal or external step therapy appeals protocol, or associated
29 clinical review criteria, such health maintenance organization shall
30 provide any enrollee or health care professional as defined in subdivi-
31 sion six of section forty-nine hundred of this chapter who may be
32 impacted by such new requirement, restriction, or amendment with written
33 notice of such new requirement, restriction, or amendment no less than
34 sixty days before implementation. Such notice may be delivered electron-
35 ically or by other means.
36 § 6. This act shall take effect immediately.
