S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                    562
 
                        2021-2022 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                (PREFILED)
 
                              January 6, 2021
                                ___________
 
 Introduced  by  M.  of  A. BRAUNSTEIN, WEPRIN, GOTTFRIED, OTIS, BRONSON,
   GALEF,  GUNTHER,  O'DONNELL,  ZEBROWSKI,  STECK,  ABINANTI,   GOODELL,
   MONTESANO,  McDONOUGH,  FRIEND -- Multi-Sponsored by -- M. of A. COOK,
   PEOPLES-STOKES, PERRY, RAMOS, J. RIVERA -- read once and  referred  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

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD03460-01-1

 A. 562                              2
 
 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.  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.