senate Bill S6586

2013-2014 Legislative Session

Relates to Medicaid reviews and appeals

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Archive: Last Bill Status - In Committee


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Feb 10, 2014 referred to social services

S6586 - Bill Details

Current Committee:
Law Section:
Social Services Law
Laws Affected:
Amd §§22 & 365-a, Soc Serv L; amd §4403-f, Pub Health L

S6586 - Bill Texts

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Provides that enrollees are not required to exhaust Medicaid appeals prior to requesting a fair hearing.

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BILL NUMBER:S6586

TITLE OF BILL: An act to amend the social services law and the public
health law, in relation to medicaid reviews and appeals

PURPOSE OR GENERAL IDEA OF BILL: To clarify that Medicaid enrollees
who have been denied services by a Medicaid managed care plan may file
for a fair hearing under the Social Services Law as well as internal
and external appeal under managed care laws, and are entitled to the
continuation of services as usual while appeals and fair hearings
proceed.

SUMMARY OF SPECIFIC PROVISIONS: The bill amends Social Services Law
22 and Public Health Law § 4403-F to assure that Medicaid enrollees do
not have to exhaust internal and external appeals of managed care plan
adverse determinations in order to proceed with Medicaid fair
hearings. The bill amends Social Services Law § 265-a to clarify that
health care services continue until the appeal(s) is resolved.

JUSTIFICATION: Medicaid recipients are increasingly moved into managed
care plans subject to the managed care internal and external appeal
processes. This is being used to assert that the recipients may not
file for a Social Services Law fair hearing until those managed care
appeals are exhausted. Unfortunately, this has the effect of depriving
recipients of their longstanding right to have services continue while
a fair hearing appeal is pending. This can have the effect of
depriving people of health care services to which they are legally
entitle.

This bill will assure that the remedies of managed care benefits
appeals are cumulative to Medicaid fair hearing rights and that health
care services once determined to be medically necessary are not
threatened by bureaucratic delays in either appeal process.

PRIOR LEGISLATIVE HISTORY: New bill

FISCAL IMPLICATIONS: None

EFFECTIVE DATE: Immediately and apply to any appeal pending at the
time.

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                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  6586

                            I N  S E N A T E

                            February 10, 2014
                               ___________

Introduced  by  Sen.  RIVERA -- read twice and ordered printed, and when
  printed to be committed to the Committee on Social Services

AN ACT to amend the social services law and the public  health  law,  in
  relation to medicaid reviews and appeals

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Section 22 of the social services law is amended by  adding
a new subdivision 15 to read as follows:
  15.  WITH  RESPECT TO MEDICAL ASSISTANCE UNDER TITLE ELEVEN OF ARTICLE
FIVE OF THIS CHAPTER, WHERE THE MEDICAL SERVICE AT ISSUE IS OR WOULD  BE
PROVIDED BY AN ENTITY SUBJECT TO ARTICLE FORTY-NINE OF THE PUBLIC HEALTH
LAW OR ARTICLE FORTY-NINE OF THE INSURANCE LAW:
  1.  AN  ENROLLEE SHALL NOT BE REQUIRED TO EXHAUST HIS OR HER REVIEW OR
APPEAL REMEDIES UNDER ARTICLE FORTY-NINE OF THE  PUBLIC  HEALTH  LAW  OR
ARTICLE FORTY-NINE OF THE INSURANCE LAW PRIOR TO REQUESTING A FAIR HEAR-
ING UNDER THIS SECTION OR ANY OTHER STATE OR FEDERAL LAW. HOWEVER, IN AN
APPROPRIATE  CASE,  THE HOLDING OR CONTINUING OF THE FAIR HEARING MAY BE
DELAYED PENDING THE OUTCOME OF SUCH REVIEW OR APPEAL.
  2. THE RIGHTS AND REMEDIES CONFERRED UNDER  THOSE  PROVISIONS  OF  THE
PUBLIC  HEALTH LAW OR THE INSURANCE LAW SHALL BE CUMULATIVE AND IN ADDI-
TION TO AND NOT IN LIEU OF ANY OTHER RIGHTS OR REMEDIES AVAILABLE  UNDER
LAW.
  S  2.  Subdivision  8  of section 365-a of the social services law, as
added by section 46-a of part B of chapter 58 of the laws  of  2009,  is
amended to read as follows:
  8.  When  a  non-governmental  entity  is authorized by the department
pursuant to contract or subcontract to make prior authorization or prior
approval determinations that may be required for  any  item  of  medical
assistance, a recipient may challenge any action taken or failure to act
in connection with a prior authorization or prior approval determination
as  if such determination were made by a government entity, and shall be
entitled to the same medical assistance benefits and  standards  and  to
the  same notice and procedural due process rights, including a right to
a fair hearing and aid continuing pursuant to section twenty-two of this

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08746-01-3

S. 6586                             2

chapter, as if the prior authorization or prior  approval  determination
were  made  by  a government entity, WITHOUT REGARD TO EXPIRATION OF THE
PRIOR SERVICE AUTHORIZATION.
  S  3.  Subparagraph  (ii) of paragraph (a) of subdivision 7 of section
4403-f of the public health law, as amended by section 41-b of part H of
chapter 59 of the laws of 2011, is amended to read as follows:
  (ii) Notwithstanding any inconsistent provision of the social services
law to the contrary, the commissioner  shall,  pursuant  to  regulation,
determine  whether  and the extent to which the applicable provisions of
the social services law or regulations relating to approvals and author-
izations of, and utilization limitations on, health and long  term  care
services reimbursed pursuant to title XIX of the federal social security
act,  including, but not limited to, fiscal assessment requirements, are
inconsistent with the flexibility necessary for the  efficient  adminis-
tration  of  managed  long  term  care  plans and such regulations shall
provide that such provisions shall not be  applicable  to  enrollees  or
managed  long  term  care  plans,  provided that such determinations are
consistent with applicable federal law and regulation,  AND  SUBJECT  TO
THE   PROVISIONS   OF   SUBDIVISION   EIGHT  OF  SECTION  THREE  HUNDRED
SIXTY-FIVE-A OF THE SOCIAL SERVICES LAW.
  S 4. This act shall take effect immediately and  shall  apply  to  any
review  or  appeal  under  the social services law, public health law or
insurance law pending at the time it becomes a law;  provided,  however,
that  the  amendments to section 4403-f of the public health law made by
section three of this act shall not affect the repeal  of  such  section
and shall be deemed repealed therewith.

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