S T A T E O F N E W Y O R K
________________________________________________________________________
7268
2023-2024 Regular Sessions
I N A S S E M B L Y
May 16, 2023
___________
Introduced by M. of A. WEPRIN, WOERNER, TAYLOR, SANTABARBARA, COLTON,
LUPARDO, STIRPE, EPSTEIN, PAULIN, NORRIS, SEAWRIGHT, SIMON, JOYNER,
LAVINE, STECK, TANNOUSIS, WALLACE, GUNTHER, L. ROSENTHAL, MEEKS, DAVI-
LA, WILLIAMS, SILLITTI -- read once and referred to the Committee on
Insurance
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-
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
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD08333-01-3
A. 7268 2
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-
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.
A. 7268 3
§ 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.