Relates to coverage of certain prescription drugs including antipsychotic, anti-depressant, anti-retroviral, anti-rejection, seizure and immunologic class drugs by Medicaid managed care providers; makes prescriber's determination final.
TITLE OF BILL: An act to amend the social services law, in relation to prescriber determination prevailing in medicaid managed care and to repeal certain provisions of such law relating thereto
PURPOSE: To clarify that prescriber prevails provisions under Medicaid managed care for certain classes of drugs shall be conducted as it currently is for fee for service Medicaid recipients.
SUMMARY OF PROVISIONS: Sections 1 and 2 of the bill amend subdivisions 25 and 25-a of section 364-j of the social services law to clarify that prescribers who, after consulting with the managed care provider, determines that such drugs in the prescriber's reasonable professional judgment are medically necessary and warranted, the prescriber's determination shall be final as is currently the case under the fee for service Medicaid program. Subdivision 25-a is repealed and those classes of drugs included within prescriber prevails in the subdivision are incorporated into subdivision 25.
Section 3 provides that this act would take effect on the 60th day after enactment, provided that effective immediately the commissioner of health may make regulations and take other actions necessary to implement the act.
JUSTIFICATION: The bill would ensure that a prescriber's determination as to which medications a patient should have access to through their Medicaid managed care plan prevails and is final. Physicians treating patients who are in the Medicaid fee for services program currently have the authority to invoke prescriber prevails without extra road blocks. As a result of prior budget actions, prescriber prevail protections were expanded for patients in the Medicaid managed care program for certain categories of drugs. This legislation ensures that patients in Medicaid managed care plans have the same protections as those in the fee for service Medicaid program, by clarifying that the prescribers' judgment and determination about which drugs should be prescribed are final.
LEGISLATIVE HISTORY: New bill.
FISCAL IMPLICATIONS: To be determined.
EFFECTIVE DATE: On the 60th day after enactment, provided that effective immediately the commissioner of health may make regulations and take other actions necessary to implement the act.
STATE OF NEW YORK ________________________________________________________________________ 4893 2015-2016 Regular Sessions IN SENATE April 23, 2015 ___________Introduced by Sen. HANNON -- read twice and ordered printed, and when printed to be committed to the Committee on Health AN ACT to amend the social services law, in relation to prescriber determination prevailing in medicaid managed care and to repeal certain provisions of such law relating thereto THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subdivision 25 of section 364-j of the social services law, as added by section 55 of part D of chapter 56 of the laws of 2012, is amended to read as follows: 25.
[Effective January first, two thousand thirteen, notwithstanding]NOTWITHSTANDING any provision of law to the contrary, managed care providers shall cover medically necessary prescription drugs in the ANTI-DEPRESSANT, ANTI-RETROVIRAL, ANTI-REJECTION, SEIZURE, EPILEPSY, ENDOCRINE, HEMATOLOGIC, IMMUNOLOGIC AND atypical antipsychotic therapeu- tic [class]CLASSES, including non-formulary drugs [, upon demonstration by]. IF the prescriber, after consulting with the managed care provider, DETERMINES that such drugs, in the prescriber's reasonable professional judgment, are medically necessary and warranted, THE PRESCRIBER'S DETER- MINATION SHALL BE FINAL. S 2. Subdivision 25-a of section 364-j of the social services law is REPEALED. S 3. This act shall take effect on the sixtieth day after it shall have become a law; provided that effective immediately, the commissioner of health may make regulations and take other actions necessary to implement this act on that date, and provided, further, that the amend- ments to section 364-j of the social services law made by this act shall not affect the repeal of such section and shall be deemed repealed ther- ewith.EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD09267-02-5