Bill Text: NY A03038 | 2019-2020 | General Assembly | Introduced
Bill Title: Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; amends provisions relating to prescription drug formulary changes and pre-authorization for certain health care services.
Spectrum: Moderate Partisan Bill (Democrat 23-5)
Status: (Introduced - Dead) 2020-01-08 - referred to insurance [A03038 Detail]
Download: New_York-2019-A03038-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 3038 2019-2020 Regular Sessions IN ASSEMBLY January 28, 2019 ___________ Introduced by M. of A. GOTTFRIED, WOERNER, TAYLOR, SANTABARBARA, LIFTON, SOLAGES, CROUCH, BARRON, COLTON, BUCHWALD, D'URSO, LUPARDO, MONTESANO, MOSLEY, ENGLEBRIGHT -- read once and referred to the Committee on Insurance AN ACT to amend the public health law and the insurance law, in relation to utilization review program standards and prescription drug formu- lary changes during a contract year, and in relation to pre-authoriza- tion of health care services The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Paragraph (c) of subdivision 1 of section 4902 of the 2 public health law, as added by chapter 705 of the laws of 1996, is 3 amended to read as follows: 4 (c) Utilization of written clinical review criteria developed pursuant 5 to a utilization review plan. Such clinical review criteria shall 6 utilize recognized evidence-based and peer reviewed clinical review 7 criteria that takes into account the needs of a typical patient popu- 8 lations and diagnoses; 9 § 2. Paragraph (a) of subdivision 2 of section 4903 of the public 10 health law, as amended by chapter 371 of the laws of 2015, is amended to 11 read as follows: 12 (a) A utilization review agent shall make a utilization review deter- 13 mination involving health care services which require pre-authorization 14 and provide notice of a determination to the enrollee or enrollee's 15 designee and the enrollee's health care provider by telephone and in 16 writing within [three business days] forty-eight hours of receipt of the 17 necessary information, or within twenty-four hours of the receipt of 18 necessary information if the request is for an enrollee with a medical 19 condition that places the health of the insured in serious jeopardy 20 without the health care services recommended by the enrollee's health 21 care professional. To the extent practicable, such written notification EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD03798-02-9A. 3038 2 1 to the enrollee's health care provider shall be transmitted electron- 2 ically, in a manner and in a form agreed upon by the parties. The 3 notification shall identify; (i) whether the services are considered 4 in-network or out-of-network; (ii) and whether the enrollee will be held 5 harmless for the services and not be responsible for any payment, other 6 than any applicable co-payment or co-insurance; (iii) as applicable, the 7 dollar amount the health care plan will pay if the service is out-of- 8 network; and (iv) as applicable, information explaining how an enrollee 9 may determine the anticipated out-of-pocket cost for out-of-network 10 health care services in a geographical area or zip code based upon the 11 difference between what the health care plan will reimburse for out-of- 12 network health care services and the usual and customary cost for out- 13 of-network health care services. An approval for a request for pre-au- 14 thorization shall be valid for the duration of the prescription or 15 treatment as requested by the enrollee's health care provider. 16 § 3. The public health law is amended by adding a new section 4909 to 17 read as follows: 18 § 4909. Prescription drug formulary changes. 1. A health care plan 19 required to provide essential health benefits shall not, except as 20 otherwise provided in subdivision two of this section, remove a 21 prescription drug from a formulary: 22 (a) if the formulary includes two or more tiers of benefits providing 23 for different deductibles, copayments or coinsurance applicable to the 24 prescription drugs in each tier, move a drug to a tier with a larger 25 deductible, copayment or coinsurance, or 26 (b) add utilization management restrictions to a formulary drug, 27 unless such changes occur at the time of enrollment or issuance of 28 coverage. Such prohibition shall apply beginning on the date on which 29 open enrollment begins for a plan year and through the end of the plan 30 year to which such open enrollment period applies. 31 2. (a) A health care plan with a formulary that includes two or more 32 tiers of benefits providing for different deductibles, copayments or 33 coinsurance applicable to prescription drugs in each tier may move a 34 prescription drug to a tier with a larger deducible, copayment or coin- 35 surance if an AB-rated generic drug for such prescription drug is added 36 to the formulary at the same time. 37 (b) A health care plan may remove a prescription drug from a formulary 38 if the federal food and drug administration determines that such drug 39 should be removed from the market. 40 § 4. Paragraph 3 of subsection (a) of section 4902 of the insurance 41 law, as added by chapter 705 of the laws of 1996, is amended to read as 42 follows: 43 (3) Utilization of written clinical review criteria developed pursuant 44 to a utilization review plan. Such clinical review criteria shall 45 utilize recognized evidence-based and peer reviewed clinical review 46 criteria that takes into account the needs of a typical patient popu- 47 lations and diagnoses; 48 § 5. Paragraph 1 of subsection (b) of section 4903 of the insurance 49 law, as amended by chapter 371 of the laws of 2015, is amended to read 50 as follows: 51 (1) A utilization review agent shall make a utilization review deter- 52 mination involving health care services which require pre-authorization 53 and provide notice of a determination to the insured or insured's desig- 54 nee and the insured's health care provider by telephone and in writing 55 within [three business days] forty-eight hours of receipt of the neces- 56 sary information, or within twenty-four hours of the receipt of neces-A. 3038 3 1 sary information if the request is for an insured with a medical condi- 2 tion that places the health of the insured in serious jeopardy without 3 the health care services recommended by the insured's health care 4 provider. To the extent practicable, such written notification to the 5 enrollee's health care provider shall be transmitted electronically, in 6 a manner and in a form agreed upon by the parties. The notification 7 shall identify: (i) whether the services are considered in-network or 8 out-of-network; (ii) whether the insured will be held harmless for the 9 services and not be responsible for any payment, other than any applica- 10 ble co-payment, co-insurance or deductible; (iii) as applicable, the 11 dollar amount the health care plan will pay if the service is out-of- 12 network; and (iv) as applicable, information explaining how an insured 13 may determine the anticipated out-of-pocket cost for out-of-network 14 health care services in a geographical area or zip code based upon the 15 difference between what the health care plan will reimburse for out-of- 16 network health care services and the usual and customary cost for out- 17 of-network health care services. An approval of request for pre-author- 18 ization shall be valid for the duration of the prescription or treatment 19 requested for pre-authorization. 20 § 6. The insurance law is amended by adding a new section 4909 to read 21 as follows: 22 § 4909. Prescription drug formulary changes. (a) A health care plan 23 required to provide essential health benefits shall not, except as 24 otherwise provided in subsection (b) of this section, remove a 25 prescription drug from a formulary: 26 (i) if the formulary includes two or more tiers of benefits providing 27 for different deductibles, copayments or coinsurance applicable to the 28 prescription drugs in each tier, move a drug to a tier with a larger 29 deductible, copayment or coinsurance, or 30 (ii) add utilization management restrictions to a formulary drug, 31 unless such changes occur at the time of enrollment or issuance of 32 coverage. Such prohibition shall apply beginning on the date on which 33 open enrollment begins for a plan year and through the end of the plan 34 year to which such open enrollment period applies. 35 (b) (i) A health care plan with a formulary that includes two or more 36 tiers of benefits providing for different deductibles, copayments or 37 coinsurance applicable to prescription drugs in each tier may move a 38 prescription drug to a tier with a larger deducible, copayment or coin- 39 surance if an AB-rated generic drug for such prescription drug is added 40 to the formulary at the same time. 41 (ii) A health care plan may remove a prescription drug from a formu- 42 lary if the federal food and drug administration determines that such 43 drug should be removed from the market. 44 § 7. Subsection (a) of section 3238 of the insurance law, as added by 45 chapter 451 of the laws of 2007, is amended to read as follows: 46 (a) An insurer, corporation organized pursuant to article forty-three 47 of this chapter, municipal cooperative health benefits plan certified 48 pursuant to article forty-seven of this chapter, or health maintenance 49 organization and other organizations certified pursuant to article 50 forty-four of the public health law ("health plan") shall pay claims for 51 a health care service for which a pre-authorization was required by, and 52 received from, the health plan prior to the rendering of such health 53 care service, and eligibility confirmed on the day of the service, 54 unless: 55 (1) [(i) the insured, subscriber, or enrollee was not a covered person56at the time the health care service was rendered.A. 3038 4 1(ii) Notwithstanding the provisions of subparagraph (i) of this para-2graph, a health plan shall not deny a claim on this basis if the3insured's, subscriber's or enrollee's coverage was retroactively termi-4nated more than one hundred twenty days after the date of the health5care service, provided that the claim is submitted within ninety days6after the date of the health care service. If the claim is submitted7more than ninety days after the date of the health care service, the8health plan shall have thirty days after the claim is received to deny9the claim on the basis that the insured, subscriber or enrollee was not10a covered person on the date of the health care service.11(2)] the submission of the claim with respect to an insured, subscrib- 12 er or enrollee was not timely under the terms of the applicable provider 13 contract, if the claim is submitted by a provider, or the policy or 14 contract, if the claim is submitted by the insured, subscriber or enrol- 15 lee; 16 [(3)] (2) at the time the pre-authorization was issued, the insured, 17 subscriber or enrollee had not exhausted contract or policy benefit 18 limitations based on information available to the health plan at such 19 time, but subsequently exhausted contract or policy benefit limitations 20 after authorization was issued; provided, however, that the health plan 21 shall include in the notice of determination required pursuant to 22 subsection (b) of section four thousand nine hundred three of this chap- 23 ter and subdivision two of section forty-nine hundred three of the 24 public health law that the visits authorized might exceed the limits of 25 the contract or policy and accordingly would not be covered under the 26 contract or policy; 27 [(4)] (3) the pre-authorization was based on materially inaccurate or 28 incomplete information provided by the insured, subscriber or enrollee, 29 the designee of the insured, subscriber or enrollee, or the health care 30 provider such that if the correct or complete information had been 31 provided, such pre-authorization would not have been granted; or 32 [(5) the pre-authorized service was related to a pre-existing condi-33tion that was excluded from coverage; or34(6)] (4) there is a reasonable basis supported by specific information 35 available for review by the superintendent that the insured, subscriber 36 or enrollee, the designee of the insured, subscriber or enrollee, or the 37 health care provider has engaged in fraud or abuse. 38 § 8. This act shall take effect on the ninetieth day after it shall 39 have become a law.
