S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4838
 
                        2021-2022 Regular Sessions
 
                             I N  S E N A T E
 
                             February 16, 2021
                                ___________
 
 Introduced  by  Sen.  BIAGGI -- read twice and ordered printed, and when
   printed to be committed to the Committee on Insurance
 
 AN ACT to amend the insurance law and the public health law, in relation
   to shortening time frames during which an  insurer  has  to  determine
   whether a pre-authorization request is medically necessary

   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Paragraph 1 of subsection (b) of section 4903 of the insur-
 ance law, as separately amended by section 16 of part YY and  section  7
 of  part  KKK  of  chapter 56 of the laws of 2020, is amended to read as
 follows:
   (1) A utilization review agent shall make a utilization review  deter-
 mination  involving health care services which require pre-authorization
 and provide notice of a determination to the insured or insured's desig-
 nee and the insured's health care provider by telephone and  in  writing
 within three [business] days of receipt of the necessary information, or
 for  inpatient  rehabilitation  services following an inpatient hospital
 admission provided by a hospital or skilled nursing facility, within one
 business day of receipt of the necessary information.  The  notification
 shall  identify:  (i)  whether the services are considered in-network or
 out-of-network; (ii) whether the insured will be held harmless  for  the
 services and not be responsible for any payment, other than any applica-
 ble  co-payment,  co-insurance  or  deductible; (iii) as applicable, the
 dollar amount the health care plan will pay if the  service  is  out-of-
 network;  and  (iv) as applicable, information explaining how an insured
 may determine the  anticipated  out-of-pocket  cost  for  out-of-network
 health  care  services in a geographical area or zip code based upon the
 difference between what the health care plan will reimburse for  out-of-
 network  health  care services and the usual and customary cost for out-
 of-network health care services.

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03460-01-1
              

 S. 4838                             2
 
   § 2. Paragraph (a) of subdivision 2 of  section  4903  of  the  public
 health law, as separately amended by section 13 of part YY and section 3
 of  part  KKK  of  chapter 56 of the laws of 2020, is amended to read as
 follows:
   (a)  A utilization review agent shall make a utilization review deter-
 mination involving health care services which require  pre-authorization
 and  provide  notice  of  a  determination to the enrollee or enrollee's
 designee and the enrollee's health care provider  by  telephone  and  in
 writing  within three [business] days of receipt of the necessary infor-
 mation. The notification shall identify; (i) whether  the  services  are
 considered  in-network  or out-of-network; (ii) and whether the enrollee
 will be held harmless for the services and not be  responsible  for  any
 payment,  other than any applicable co-payment or co-insurance; (iii) as
 applicable, the dollar amount the health  care  plan  will  pay  if  the
 service  is out-of-network; and (iv) as applicable, information explain-
 ing how an enrollee may determine the anticipated out-of-pocket cost for
 out-of-network health care services in a geographical area or  zip  code
 based  upon  the difference between what the health care plan will reim-
 burse for out-of-network health care services and the usual and  custom-
 ary cost for out-of-network health care services.
   § 3. This act shall take effect immediately.