BILL NUMBER: S2677A
SPONSOR: BRESLIN
 
TITLE OF BILL:
An act to amend the insurance law and the public health law, in relation
to requiring notice of adverse step therapy determinations
 
PURPOSE OR GENERAL IDEA OF BILL:
The purpose of this bill is to require notice of an adverse determi-
nation related to a step therapy protocol override determination request
to the patient and their prescribing healthcare professional.
 
SUMMARY OF PROVISIONS:
Section one amends section 4902 of the insurance law by adding a new
paragraph (14) that establishes a written procedure for the notice of an
adverse determination related to a step therapy protocol override deter-
mination request includes certain criteria. The bill explicitly states
the request must include the reasons for the determination including the
clinical rationale. In addition, it requires instructions on how to
initiate standard and expedited appeals. Finally, it requires informa-
tion that includes any applicable alternative covered, the clinical
review criteria relied upon, and any additional necessary information
the utilization review agent relied upon to render such decision.
Section two amends section 4903 of the insurance law to require the
aforementioned notice of an adverse determination made by a utilization
review agent related to a step therapy protocol override determination
request. Such notice is required to be made in writing to the insured or
their agent and their prescribing healthcare professional. The notice
must include the written procedure as required in section one.
The provisions of this section shall be satisfied by making such infor-
mation available electronically on a formulary website, on the member
portal and/or provider portal of the insurer, health maintenance organ-
izations, or article forty-three organizations website, provided that
the member consents to receiving the information electronically.
Section three amends section 4902 of the public health law with the same
required written procedure guidelines as section one.
Section four amends section 4903 of the public health law with the same
notice requirements for enrollees as section two.
Section five establishes the effective date, 90 days after it shall
become law.
 
JUSTIFICATION:
Providing information on step therapy protocols allows patients to make
informed decisions when selecting a health plan. It also allows patients
and health care professionals to more easily request step therapy over-
rides and appeals and plan for efficient treatment.
 
PRIOR LEGISLATIVE HISTORY:
S8194 - 2021/22
 
FISCAL IMPLICATIONS:
None
 
EFFECTIVE DATE:
This act shall take effect on the ninetieth day after it shall become
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.

Statutes affected:
S2677: 4903 insurance law, 4902 public health law, 4902(1) public health law, 4903 public health law
S2677A: 4903 insurance law, 4902 public health law, 4902(1) public health law, 4903 public health law