Provides that a utilization review agent shall not issue an adverse determination denying, reducing, or terminating coverage for medically necessary skilled rehabilitation services solely because the insured or enrollee has failed to demonstrate measurable improvement in the insured's or enrollee's condition.
S T A T E O F N E W Y O R K
________________________________________________________________________
11673
I N A S S E M B L Y
September 2, 2026
___________
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Weprin) --
read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to prohibiting the termi-
nation of coverage for rehabilitation services solely because of a
failure to demonstrate measurable improvement in the applicable condi-
tion
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Section 4903 of the insurance law is amended by adding a
new subsection (j) to read as follows:
(J) (1) A UTILIZATION REVIEW AGENT SHALL NOT ISSUE AN ADVERSE DETERMI-
NATION DENYING, REDUCING, OR TERMINATING COVERAGE FOR MEDICALLY NECES-
SARY SKILLED REHABILITATION SERVICES SOLELY BECAUSE THE INSURED OR
ENROLLEE HAS FAILED TO DEMONSTRATE MEASURABLE IMPROVEMENT IN THE
INSURED'S OR ENROLLEE'S CONDITION.
(2) FOR PURPOSES OF THIS SUBSECTION, MEDICALLY NECESSARY SKILLED REHA-
BILITATION SERVICES MAY INCLUDE PHYSICAL THERAPY, OCCUPATIONAL THERAPY,
SPEECH-LANGUAGE PATHOLOGY SERVICES, PULMONARY REHABILITATION, CARDIAC
REHABILITATION, AND OTHER REHABILITATIVE SERVICES PERFORMED BY A
LICENSED HEALTH CARE PROFESSIONAL ACTING WITHIN THE SCOPE OF THEIR PRAC-
TICE.
(3) A UTILIZATION REVIEW AGENT SHALL CONSIDER WHETHER CONTINUED
SKILLED SERVICES ARE REASONABLY EXPECTED TO:
(I) MAINTAIN THE INSURED'S OR ENROLLEE'S CURRENT LEVEL OF FUNCTION;
(II) PREVENT OR SLOW DETERIORATION IN FUNCTIONAL CAPACITY;
(III) REDUCE PAIN OR OTHER SYMPTOMS THAT IMPAIR ACTIVITIES OF DAILY
LIVING;
(IV) PREVENT HOSPITALIZATION, INSTITUTIONALIZATION, SURGERY, OR OTHER
MORE INTENSIVE MEDICAL INTERVENTION; OR
(V) PERMIT THE SAFE PERFORMANCE OF A MAINTENANCE PROGRAM REQUIRING THE
SPECIALIZED CLINICAL JUDGMENT OR SKILLS OF A LICENSED HEALTH CARE
PROFESSIONAL.
(4) AN ADVERSE DETERMINATION SHALL NOT BE BASED SOLELY UPON A FINDING
THAT THE INSURED OR ENROLLEE HAS REACHED A PLATEAU, HAS FAILED TO DEMON-
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
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