S T A T E O F N E W Y O R K
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Cal. No. 63
2009-2010 Regular Sessions
I N A S S E M B L Y
(PREFILED)
January 7, 2009
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Introduced by M. of A. GOTTFRIED, CANESTRARI, DINOWITZ, JACOBS, JOHN,
PAULIN, KAVANAGH, SCARBOROUGH -- Multi-Sponsored by -- M. of A.
ABBATE, AUBRY, BING, BRENNAN, CLARK, COLTON, COOK, CUSICK, CYMBROWITZ,
ENGLEBRIGHT, GALEF, GLICK, HEASTIE, HOOPER, KELLNER, LIFTON, MAYER-
SOHN, McENENY, MILLMAN, ORTIZ, PEOPLES-STOKES, PERRY, PHEFFER,
J. RIVERA, ROBINSON, SWEENEY, TOWNS, WEISENBERG -- read once and
referred to the Committee on Health -- reported from committee,
advanced to a third reading, amended and ordered reprinted, retaining
its place on the order of third reading
AN ACT to amend the public health law and the insurance law, in relation
to notification of an enrollee's designee and the enrollee's health
care provider of the initiation of an external appeal and the appeal
determination; and to repeal certain provisions of the public health
law and the insurance law allowing a health care plan to charge an
insured a fee for an appeal
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subdivision 3 of section 4910 of the public health law is
REPEALED.
S 2. Paragraphs (a) and (b) of subdivision 2 of section 4914 of the
public health law, paragraph (a) as added by chapter 586 of the laws of
1998 and paragraph (b) as amended by chapter 237 of the laws of 2009,
are amended to read as follows:
(a) The enrollee shall have forty-five days to initiate an external
appeal after the enrollee [receives], THE ENROLLEE'S DESIGNEE, IF ANY,
AND THE ENROLLEE'S HEALTH CARE PROVIDER, RECEIVE notice from the health
care plan, or such plan's utilization review agent if applicable, of a
final adverse determination or denial or after both the plan and the
enrollee have jointly agreed to waive any internal appeal. Such request
shall be in writing in accordance with the instructions and in such form
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD00977-02-0
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prescribed by subdivision five of this section. The enrollee, and the
enrollee's health care provider where applicable, shall have the oppor-
tunity to submit additional documentation with respect to such appeal to
the external appeal agent within such forty-five-day period; provided
however that when such documentation represents a material change from
the documentation upon which the utilization review agent based its
adverse determination or upon which the health plan based its denial,
the health plan shall have three business days to consider such documen-
tation and amend or confirm such adverse determination.
(b) The external appeal agent shall make a determination with respect
to the appeal within thirty days of the receipt of the request therefor,
submitted in accordance with the commissioner's instructions. The
external appeal agent shall have the opportunity to request additional
information from the enrollee, the enrollee's health care provider and
the enrollee's health care plan within such thirty-day period, in which
case the agent shall have up to five additional business days if neces-
sary to make such determination. The external appeal agent shall notify
the enrollee, THE ENROLLEE'S DESIGNEE, IF ANY, the enrollee's health
care provider where appropriate, and the health care plan, in writing,
of the appeal determination within two business days of the rendering of
such determination.
S 3. Subsection (c) of section 4910 of the insurance law is REPEALED.
S 4. Paragraphs 1 and 2 of subsection (b) of section 4914 of the
insurance law, paragraph 1 as added by chapter 586 of the laws of 1998
and paragraph 2 as amended by chapter 237 of the laws of 2009, are
amended to read as follows:
(1) The insured shall have forty-five days to initiate an external
appeal after the insured [receives], THE INSURED'S DESIGNEE, IF ANY, AND
THE INSURED'S HEALTH CARE PROVIDER, RECEIVE notice from the health care
plan, or such plan's utilization review agent if applicable, of a final
adverse determination or denial or after both the plan and the enrollee
have jointly agreed to waive any internal appeal. Such request shall be
in writing in accordance with the instructions and in such form
prescribed by subsection (e) of this section. The insured, and the
insured's health care provider where applicable, shall have the opportu-
nity to submit additional documentation with respect to such appeal to
the external appeal agent within such forty-five-day period; provided
however that when such documentation represents a material change from
the documentation upon which the utilization review agent based its
adverse determination or upon which the health plan based its denial,
the health plan shall have three business days to consider such documen-
tation and amend or confirm such adverse determination.
(2) The external appeal agent shall make a determination with regard
to the appeal within thirty days of the receipt of the request therefor,
submitted in accordance with the superintendent's instructions. The
external appeal agent shall have the opportunity to request additional
information from the insured, the insured's health care provider and the
insured's health care plan within such thirty-day period, in which case
the agent shall have up to five additional business days if necessary to
make such determination. The external appeal agent shall notify the
insured, THE INSURED'S DESIGNEE, IF ANY, the insured's health care
provider where appropriate, and the health care plan, in writing, of the
appeal determination within two business days of the rendering of such
determination.
S 5. This act shall take effect on the one hundred eightieth day after
it shall become a law.
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REPEAL NOTE.--Subdivision 3 of section 4910 of the public health law
repealed by section one of this act and subsection (c) of section 4910
of the insurance law repealed by section three of this act, allows the
health care plan to charge an insured a fee of up to fifty dollars per
external appeal.