BILL NUMBER: S4867A
SPONSOR: FAHY
 
TITLE OF BILL:
An act to amend the insurance law, in relation to prohibiting the appli-
cation of fail-first or step therapy protocols to coverage for the diag-
nosis and treatment of serious mental health conditions
 
PURPOSE:
This bill would prohibit the application of fail-first or step therapy
protocols or prior authorization requirements to coverage for the diag-
nosis and treatment of serious mental health conditions.
 
SUMMARY OF SPECIFIC PROVISIONS:
Section one would amend subsection (i) of section 3216 of the insurance
law to prohibit the application of any fail-first or step therapy proto-
col or the implementation of prior authorization requirements to drug
coverage for treatment of serious mental health conditions provided by
individual accident and health insurance policies. Serious Mental Health
Condition is defined as disorders in the most recent edition of the
diagnostic and statistical manual of mental disorders, including neuro-
developmental disorders, schizophrenia spectrum and other psychotic
disorders, bipolar and related disorders, depressive disorders, anxiety
disorders, obsessive-compulsive and related disorders, trauma- and
stressor- related disorders, neurodegenerative disorders, substance-re-
lated and addictive disorders.
Section two would amend subsection (1) of section 3221 of the insurance
law to make these same provisions applicable to group or blanket acci-
dent and health insurance policies.
Section three would amend subsection (g) of section 4303 of the insur-
ance law to make these provisions applicable to non-profit medical and
dental indemnity policies.
Section four provides that the bill would take effect on the first of
January next succeeding the date at which it shall become a law, and
shall apply to all policies and contracts issued, renewed, modified,
altered or amended on or after such date.
 
JUSTIFICATION:
"Fail-first" or "step therapy" protocols imposed by insurers obligate
patients to try a less costly and potentially less effective treatment
than what might be prescribed and preferred by their provider, and "fail
first" with that before the insurer will cover the more costly treat-
ment. This often requires patients to take medications that they have
tried previously without success, to wait months for approval to switch
to another medication after failing with a given drug, or to suffer
adverse effects from a drug they did not want to take.
Published studies on the impact of step therapy policies have found
that, contrary to their intent, such policies can increase total utili-
zation costs over the long run because of increased inpatient admissions
and emergency department visits and increasing the time it takes for
these patients to "stabilize" on the medications that actually work to
treat their condition. Similarly, prior authorization requirements add
lengthy delays for patients to access treatment, especially for
prescription drugs. These types of policies and restrictions are espe-
cially dangerous when dealing with treatment of serious mental health
conditions. People suffering from these dangerous conditions often are
at severe risk of deterioration, self-harm and harm to others if they
cannot access their needed medication in a timely, consistent manner.
While New York State's insurance laws already require the treatment of
mental health conditions to not apply treatment limitations that are
more restrictive as all other medical and surgical benefits, this does
not prohibit the use of such limitations on serious conditions.
Treatment limitations such as step therapy, fail-first protocols and
prior authorization requirements for prescription drugs that treat seri-
ous mental health conditions is not in the therapeutic best interest of
patients. Sometimes it takes weeks or months to find the "right" medica-
tion or dosage to stabilize a patient. Subjecting patients to these
treatment limitations can postpone recovery, and even increase the like-
lihood of morbidity of patients.
 
LEGISLATIVE HISTORY:
2023/2024 - S.6688A/A.7522
 
FISCAL IMPLICATIONS:
None to the state.
 
EFFECTIVE DATE:
This act shall take effect on the first of January next succeeding the
date at which it shall have become a law and shall apply to all policies
and contracts issued, renewed, modified, altered or amended on or after
such date.