S T A T E O F N E W Y O R K
________________________________________________________________________
5129--A
2015-2016 Regular Sessions
I N A S S E M B L Y
February 12, 2015
___________
Introduced by M. of A. BRAUNSTEIN, WEPRIN, GOTTFRIED, OTIS, BRONSON,
SKOUFIS, GALEF, GUNTHER, CRESPO, O'DONNELL, GOODELL, MONTESANO,
ZEBROWSKI, McDONOUGH, HOOPER, STECK, ABINANTI, FRIEND -- Multi-Spon-
sored by -- M. of A. COOK, KEARNS, PEOPLES-STOKES, PERRY, RAMOS,
RIVERA, SCHIMEL, SEPULVEDA, SIMANOWITZ -- read once and referred to
the Committee on Insurance -- recommitted to the Committee on Insur-
ance in accordance with Assembly Rule 3, sec. 2 -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee
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. Subsection (b) of section 4903 of the insurance law, as
amended by section 12 of part H of chapter 60 of the laws of 2014, is
amended to read as follows:
(b) 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. To
the extent practicable, such written notification to the enrollee's
health care provider shall be transmitted electronically, in a manner
and in a form agreed upon by the parties. The notification shall iden-
tify: (1) whether the services are considered in-network or out-of-net-
work; (2) whether the insured will be held harmless for the services and
not be responsible for any payment, other than any applicable co-pay-
ment, co-insurance or deductible; (3) as applicable, the dollar amount
the health care plan will pay if the service is out-of-network; and (4)
as applicable, information explaining how an insured may determine the
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03427-04-6
A. 5129--A 2
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.
S 1-a. Subsection (b) of section 4903 of the insurance law, as amended
by chapter 371 of the laws of 2015, is amended to read as follows:
(b) (1) A utilization review agent shall make a utilization review
determination involving health care services which require pre-authori-
zation and provide notice of a determination to the insured or insured's
designee and the insured's health care provider by telephone and in
writing within three [business] days of receipt of the necessary infor-
mation. To the extent practicable, such written notification to the
enrollee's health care provider shall be transmitted electronically, in
a manner and in a form agreed upon by the parties. 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.
(2) With regard to individual or group contracts authorized pursuant
to article thirty-two, forty-three or forty-seven of this chapter or
article forty-four of the public health law, for utilization and review
determinations involving proposed mental health and/or substance use
disorder services where the insured or the insured's designee has, in a
format prescribed by the superintendent, certified in the request that
the proposed services are for an individual who will be appearing, or
has appeared, before a court of competent jurisdiction and may be
subject to a court order requiring such services, the utilization review
agent shall make a determination and provide notice of such determi-
nation to the insured or the insured's designee by telephone within
seventy-two hours of receipt of the request. Written notice of the
determination to the insured or insured's designee shall follow within
three business days. Where feasible, such telephonic and written notice
shall also be provided to the court.
S 2. Subdivision 2 of section 4903 of the public health law, as
amended by section 22 of part H of chapter 60 of the laws of 2014, is
amended to read as follows:
2. A utilization review agent shall make a utilization review determi-
nation 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. To the extent practicable, such written notification to the
enrollee's health care provider shall be transmitted electronically, in
a manner and in a form agreed upon by the parties. The notification
shall identify; (a) whether the services are considered in-network or
out-of-network; (b) 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; (c) as applicable, the dollar
A. 5129--A 3
amount the health care plan will pay if the service is out-of-network;
and (d) as applicable, information explaining how an enrollee may deter-
mine 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.
S 2-a. Subdivision 2 of section 4903 of the public health law, as
amended by chapter 371 of the laws of 2015, is amended to read as
follows:
2. (a) A utilization review agent shall make a utilization review
determination involving health care services which require pre-authori-
zation 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
information. To the extent practicable, such written notification to the
enrollee's health care provider shall be transmitted electronically, in
a manner and in a form agreed upon by the parties. 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 explaining 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 differ-
ence 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.
(b) With regard to individual or group contracts authorized pursuant
to article forty-four of this chapter, for utilization review determi-
nations involving proposed mental health and/or substance use disorder
services where the enrollee or the enrollee's designee has, in a format
prescribed by the superintendent of financial services, certified in the
request that the proposed services are for an individual who will be
appearing, or has appeared, before a court of competent jurisdiction and
may be subject to a court order requiring such services, the utilization
review agent shall make a determination and provide notice of such
determination to the enrollee or the enrollee's designee by telephone
within seventy-two hours of receipt of the request. Written notice of
the determination to the enrollee or enrollee's designee shall follow
within three business days. Where feasible, such telephonic and written
notice shall also be provided to the court.
S 3. This act shall take effect immediately, provided, however, that
sections one-a and two-a of this act shall take effect on the same date
and in the same manner as chapter 371 of the laws of 2015, takes effect.