N.Y. Social Services Law § 365-d: Medicaid evidence based benefit review advisory committee

§ 365-d. Medicaid evidence based benefit review advisory committee. 1.

The department shall convene a Medicaid evidence based benefit review

advisory committee. The committee shall provide advice and make

recommendations regarding coverage of health technology or service for

purposes of the medical assistance program. The commissioner shall

consult such committee prior to any determination made regarding the

coverage status of a particular item, health technology or service based

on procedures established in subdivision five of this section under the

medical assistance program. For purposes of this section, "health

technology" means medical devices and surgical procedures used in the

prevention, diagnosis and treatment of disease and other medical

conditions. For purposes of this section "services" means any medical or

behavioral health procedure.

2. (a) The membership of such committee shall, at a minimum, include:

(i) at least three persons licensed and actively engaged in the

practice of medicine in this state;

(ii) one person licensed and actively engaged in the practice of

nursing as a nurse practitioner, or in the practice of midwifery in this

state;

(iii) one person with expertise in health technology assessment or

evidence based medical review who is preferably a health care

professional licensed under title eight of the education law;

(iv) three persons who shall be consumers or representatives of

organizations with a regional or statewide constituency and who have

been involved in activities related to health care consumer advocacy;

(v) one person who is a representative of a hospital organization with

a regional, national or statewide constituency;

(vi) one person who is a representative of a health insurance or

managed care organization with a regional, statewide or national

constituency;

(vii) one person who is a health economist;

(viii) one person with health care expertise who is appointed by the

temporary president of the senate;

(ix) one person with health care expertise who is appointed by the

speaker of the assembly;

(x) a member of the department who shall act as chairperson as

designated by the commissioner; and

(xi) the committee may invite and consult with scientific, technical,

or clinical experts with demonstrable experience or knowledge of the

technology or medical specialty area under review.

3. The department shall provide video or audio access to all meetings

of such committee through the department's website.

4. The members of the committee shall receive no compensation for

their services but shall be reimbursed for expenses actually and

necessarily incurred in the performance of their duties unless expressly

stated otherwise in this section, members shall be appointed by the

commissioner. Members shall serve three year terms, and may be

reappointed for subsequent terms. Committee members shall be deemed to

be employees of the department for purposes of section seventeen of the

public officers law, and shall not participate in any matter before the

committee for which a conflict of interest exists.

5. The committee shall consider any matter regarding material changes

in the coverage status of a particular item, health technology or

service, and any matter relative to new health technology assessment or

medical evidence review for which the department determines a sufficient

body of evidence exists to warrant committee deliberation. The

commissioner shall provide members of the committee with any evidence or

information related to the health technology or medical service

assessment including but not limited to, information submitted by

members of the public. The department shall report to the committee

programmatic changes to benefits that do not rise to the level of a

material change, as well as determinations of when sufficient medical

evidence exists to warrant committee deliberations. The commissioner

shall provide forty-five days public notice on the department's website

prior to any meeting of the committee to develop recommendations

concerning health technology or medical service coverage determinations.

Such notice shall include a description of the proposed health

technology or service to be reviewed, the conditions or diseases

impacted by the health technology or service, the proposals to be

considered by the committee, and the systematic evidence-based

assessment prepared in accordance with this subdivision. The committee

shall allow interested parties a reasonable opportunity to make an oral

presentation to the committee related to the health technology or

service to be reviewed and to submit written information. The committee

shall consider any information provided by any interested party,

including, but not limited to, health care providers, health care

facilities, patients, consumers and manufacturers. For all health

technologies or services selected for review, the department shall

conduct or commission a systematic evidence-based assessment of the

health technology's or service's safety and clinical efficacy. The

assessment shall use established systematic review elements, study

quality assessment, and data synthesis. Upon completion, the systematic,

evidence-based assessment shall be made available to the public.

6. The commissioner shall provide notice of any coverage

recommendations developed by the committee by making such information

available on the department's website. Such public notice shall include:

a summary of the deliberations of the committee; a summary of the

positions of those making public comments at meetings of the committee

and any safety and health outcomes data submitted by any interested

party; the response of the committee to those comments, if any; the

clinical evidence upon which the committee bases its recommendations;

and the findings and recommendations of the committee including a final

evidence-based systematic assessment.

7. The commissioner shall provide public notice on the department's

website of the committee's recommendation and the department's final

determination, including: the nature of the determination; an analysis

of the impact of the department's determination on the state Medicaid

plan populations and providers; and the projected fiscal impact to the

state Medicaid program.

8. The recommendations of the committee, made pursuant to this

section, shall be based on a review of the evidence presented to the

committee, including the clinical effectiveness, patient outcomes,

impact on at risk and underserved populations, and safety. The committee

shall review previous recommendations of the committee as new evidence

becomes available and permit oral presentations and the submission of

new evidence at any committee meeting. Such review shall occur pursuant

to the procedure established in subdivisions five and six of this

section. The department may alter or revoke the final determination

after such review pursuant to the procedure established in subdivision

seven of this section.

9. The department shall provide administrative support to the

committee.