Relates to coverage of certain prescription drugs by Medicaid managed care providers; repealer

1 Co-sponsor

• David Carlucci

BILL NUMBER:S4893

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, deter- mines that such drugs in the prescriber's reasonable professional judg- ment are medically necessary and warranted, the prescriber's determi- nation 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 Subdivision 25-a is repealed and those classes of drugs included within prescriber prevails in the subdivision are incor- porated into subdivision 25.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 imple- ment 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.