S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  7129--A
 
                        2021-2022 Regular Sessions
 
                           I N  A S S E M B L Y
 
                              April 23, 2021
                                ___________
 
 Introduced  by M. of A. GOTTFRIED, WOERNER, TAYLOR, SANTABARBARA, SOLAG-
   ES, COLTON, LUPARDO, MONTESANO, ENGLEBRIGHT, STIRPE, EPSTEIN,  THIELE,
   PAULIN,  WALCZYK, NORRIS, SEAWRIGHT, SIMON, ABINANTI, JOYNER, M. MILL-
   ER, LAVINE, STECK, TANNOUSIS -- read once and referred to the  Commit-
   tee  on  Insurance  --  recommitted  to  the Committee on Insurance in
   accordance with Assembly Rule 3, sec. 2 -- committee discharged,  bill
   amended,  ordered reprinted as amended and recommitted to said commit-
   tee
 
 AN ACT to amend the public health law and the insurance law, in relation
   to utilization review program standards, and in  relation  to  pre-au-
   thorization of health care services
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1.  Paragraph (c) of subdivision 1  of  section  4902  of  the
 public  health  law,  as  added  by  chapter 705 of the laws of 1996, is
 amended to read as follows:
   (c) Utilization of written clinical review criteria developed pursuant
 to a utilization  review  plan.  SUCH  CLINICAL  REVIEW  CRITERIA  SHALL
 UTILIZE  RECOGNIZED  EVIDENCE-BASED  AND  PEER  REVIEWED CLINICAL REVIEW
 CRITERIA THAT TAKE INTO ACCOUNT THE NEEDS OF  A  TYPICAL  PATIENT  POPU-
 LATIONS AND DIAGNOSES;
   §  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] SEVENTY-TWO HOURS of receipt of the
 necessary information, WITHIN TWENTY-FOUR HOURS OF THE RECEIPT OF NECES-
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03897-05-2
              

 A. 7129--A                          2
 
 SARY INFORMATION IF THE REQUEST IS FOR AN ENROLLEE WITH A MEDICAL CONDI-
 TION  THAT  PLACES THE HEALTH OF THE INSURED IN SERIOUS JEOPARDY WITHOUT
 THE HEALTH CARE SERVICES  RECOMMENDED  BY  THE  ENROLLEE'S  HEALTH  CARE
 PROFESSIONAL,  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 informa-
 tion. 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. AN APPROVAL FOR A
 REQUEST FOR PRE-AUTHORIZATION SHALL BE VALID FOR (1) THE DURATION OF THE
 PRESCRIPTION, INCLUDING ANY AUTHORIZED REFILLS AND (2) THE  DURATION  OF
 TREATMENT FOR A SPECIFIC CONDITION AS REQUESTED BY THE ENROLLEE'S HEALTH
 CARE PROVIDER.
   §  3.  Paragraph  3 of subsection (a) of section 4902 of the insurance
 law, as added by chapter 705 of the laws of 1996, is amended to read  as
 follows:
   (3) Utilization of written clinical review criteria developed pursuant
 to  a  utilization  review  plan.  SUCH  CLINICAL  REVIEW CRITERIA SHALL
 UTILIZE RECOGNIZED EVIDENCE-BASED  AND  PEER  REVIEWED  CLINICAL  REVIEW
 CRITERIA  THAT  TAKE  INTO  ACCOUNT THE NEEDS OF A TYPICAL PATIENT POPU-
 LATIONS AND DIAGNOSES;
   § 4. Paragraph 1 of subsection (b) of section 4903  of  the  insurance
 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] SEVENTY-TWO HOURS of receipt of the  neces-
 sary  information,  WITHIN  TWENTY-FOUR  HOURS  OF  RECEIPT OF NECESSARY
 INFORMATION IF THE REQUEST IS FOR AN INSURED WITH  A  MEDICAL  CONDITION
 THAT  PLACES  THE  HEALTH OF THE INSURED IN SERIOUS JEOPARDY WITHOUT THE
 HEALTH CARE SERVICES RECOMMENDED BY THE INSURED'S HEALTH CARE  PROVIDER,
 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
 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. AN APPROVAL OF REQUEST FOR PRE-AUTHORI-
 A. 7129--A                          3
 
 ZATION  SHALL  BE  VALID  FOR  (1)  THE  DURATION  OF  THE PRESCRIPTION,
 INCLUDING ANY AUTHORIZED REFILLS AND (2) THE DURATION OF TREATMENT FOR A
 SPECIFIC CONDITION REQUESTED FOR PRE-AUTHORIZATION.
   §  5. Subsection (a) of section 3238 of the insurance law, as added by
 chapter 451 of the laws of 2007, is amended to read as follows:
   (a) An insurer, corporation organized pursuant to article  forty-three
 of  this  chapter,  municipal cooperative health benefits plan certified
 pursuant to article forty-seven of this chapter, or  health  maintenance
 organization  and  other  organizations  certified  pursuant  to article
 forty-four of the public health law ("health plan") shall pay claims for
 a health care service for which a pre-authorization was required by, and
 received from, the health plan prior to the  rendering  of  such  health
 care  service,  AND  ELIGIBILITY  CONFIRMED  ON  THE DAY OF THE SERVICE,
 unless:
   (1) [(i) the insured, subscriber, or enrollee was not a covered person
 at the time the health care service was rendered.
   (ii) Notwithstanding the provisions of subparagraph (i) of this  para-
 graph,  a  health  plan  shall  not  deny  a  claim on this basis if the
 insured's, subscriber's or enrollee's coverage was retroactively  termi-
 nated  more  than  one  hundred twenty days after the date of the health
 care service, provided that the claim is submitted  within  ninety  days
 after  the  date  of  the health care service. If the claim is submitted
 more than ninety days after the date of the  health  care  service,  the
 health  plan  shall have thirty days after the claim is received to deny
 the claim on the basis that the insured, subscriber or enrollee was  not
 a covered person on the date of the health care service.
   (2)] the submission of the claim with respect to an insured, subscrib-
 er or enrollee was not timely under the terms of the applicable provider
 contract,  if  the  claim  is  submitted by a provider, or the policy or
 contract, if the claim is submitted by the insured, subscriber or enrol-
 lee;
   [(3)] (2) at the time the pre-authorization was issued,  the  insured,
 subscriber  or  enrollee  had  not  exhausted contract or policy benefit
 limitations based on information available to the health  plan  at  such
 time,  but subsequently exhausted contract or policy benefit limitations
 after authorization was issued; provided, however, that the health  plan
 shall  include  in  the  notice  of  determination  required pursuant to
 subsection (b) of section four thousand nine hundred three of this chap-
 ter and subdivision two of  section  forty-nine  hundred  three  of  the
 public  health law that the visits authorized might exceed the limits of
 the contract or policy and accordingly would not be  covered  under  the
 contract or policy;
   [(4)]  (3) the pre-authorization was based on materially inaccurate or
 incomplete information provided by the insured, subscriber or  enrollee,
 the  designee of the insured, subscriber or enrollee, or the health care
 provider such that if the  correct  or  complete  information  had  been
 provided, such pre-authorization would not have been granted; OR
   [(5)  the  pre-authorized service was related to a pre-existing condi-
 tion that was excluded from coverage; or
   (6)] (4) there is a reasonable basis supported by specific information
 available for review by the superintendent that the insured,  subscriber
 or enrollee, the designee of the insured, subscriber or enrollee, or the
 health care provider has engaged in fraud or abuse.
   §  6.  This  act shall take effect on the ninetieth day after it shall
 have become a law.