S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                    862
 
                        2017-2018 Regular Sessions
 
                           I N  A S S E M B L Y
 
                              January 9, 2017
                                ___________
 
 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, SEPULVEDA, SIMANOWITZ -- read once and referred to the Commit-
   tee 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.    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-
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD01749-01-7

 A. 862                              2
 
 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.
   § 2. 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.
   § 3. This act shall take effect immediately.