S T A T E O F N E W Y O R K
________________________________________________________________________
3789--A
2025-2026 Regular Sessions
I N A S S E M B L Y
January 30, 2025
___________
Introduced by M. of A. WEPRIN, WOERNER, TAYLOR, SANTABARBARA, COLTON,
LUPARDO, STIRPE, EPSTEIN, PAULIN, SEAWRIGHT, SIMON, LAVINE, STECK,
TANNOUSIS, ROSENTHAL, MEEKS, DAVILA, WILLIAMS, LUNSFORD, BORES, PIROZ-
ZOLO, KELLES, R. CARROLL, SIMPSON, BENDETT, REYES, ANGELINO, SAYEGH,
LEVENBERG, RAMOS, DiPIETRO, GALLAHAN, RAGA, HEVESI, CLARK, SHRESTHA,
CUNNINGHAM, McMAHON, BARRETT, BRABENEC, KASSAY, MAGNARELLI, BUTTENS-
CHON, KAY, BLANKENBUSH, WIEDER, CRUZ -- read once and referred to the
Committee on Insurance -- reported and referred to the Committee on
Rules -- Rules Committee discharged, bill amended, ordered reprinted
as amended and recommitted to the Committee on Rules
AN ACT to amend the public health law and the insurance law, in relation
to utilization review program standards and pre-authorization 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
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD07503-02-5
A. 3789--A 2
writing within [three business days] SEVENTY-TWO HOURS of receipt of the
necessary information, or for inpatient rehabilitation services follow-
ing 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) and whether
the enrollee will be held harmless for the services and not be responsi-
ble for any payment, other than any applicable co-payment or co-insu-
rance; (iii) as applicable, the dollar amount the health care plan will
pay if the service is out-of-network; and (iv) as applicable, informa-
tion 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 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 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, 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) whether the insured will
be held harmless for the services and not be responsible for any
payment, other than any applicable co-payment, co-insurance or deduct-
ible; (iii) as applicable, the dollar amount the health care plan will
pay if the service is out-of-network; and (iv) as applicable, informa-
tion 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-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 REQUESTED FOR PRE-AU-
THORIZATION.
§ 5. This act shall take effect on the one hundred eightieth day after
it shall have become a law.