Assembly Bill A4063

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4063
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 31, 2025
                                ___________
 
 Introduced by M. of A. WEPRIN -- read once and referred to the Committee
   on Insurance
 
 AN ACT to amend the public health law and the insurance law, in relation
   to  providing that the failure by the utilization review agent to make
   a determination within certain time periods shall be deemed to  be  an
   approval of the health care services

   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Subdivision 7 of section 4903 of the public health law,  as
 amended  by  chapter  641  of  the  laws  of 2024, is amended to read as
 follows:
   7. Failure by the utilization review agent  to  make  a  determination
 within the time periods prescribed in this section shall be deemed to be
 an  [adverse  determination subject to appeal pursuant to section forty-
 nine hundred four of this title, provided, however,  that]  APPROVAL  OF
 THE HEALTH CARE SERVICES IN QUESTION AND failure to meet such time peri-
 ods  for a step therapy protocol as defined in subdivision seven-f-three
 of section forty-nine hundred of this title or a step  therapy  protocol
 override  determination  pursuant  to  subdivisions three-a, three-b and
 three-c of this section shall be deemed to be an override  of  the  step
 therapy  protocol.  A  utilization review agent's failure to comply with
 any of the step therapy protocol requirements required  in  subdivisions
 five  and  six  of section forty-nine hundred two of this title shall be
 considered a basis for granting an override of the step  therapy  proto-
 col, absent fraud.
   §  2.  Subsection (g) of section 4903 of the insurance law, as amended
 by chapter 641 of the laws of 2024, is amended to read as follows:
   (g) Failure by the utilization review agent to  make  a  determination
 within the time periods prescribed in this section shall be deemed to be
 an  [adverse  determination  subject  to appeal pursuant to section four
 thousand nine hundred four of this title, provided,  however,]  APPROVAL
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD08002-01-5
              

 A. 4063                             2
 
 OF  THE  HEALTH  CARE SERVICES IN QUESTION AND that failure to meet such
 time periods for a step therapy protocol as defined in subsection  (g-9)
 of  section  forty-nine hundred of this title or a step therapy protocol
 override determination pursuant to subsections (c-1), (c-2) and (c-3) of
 this  section  shall  be  deemed  to  be an override of the step therapy
 protocol. A utilization review agent's failure to comply with any of the
 step therapy protocol requirements required in [subsections]  PARAGRAPHS
 fifteen  and  sixteen  of  SUBSECTION  (A) OF section four thousand nine
 hundred two of this title shall be considered a basis  for  granting  an
 override of the step therapy protocol, absent fraud.
   §  3.  This  act  shall  take  effect on the same date and in the same
 manner as section 4 of chapter 641 of the laws of  2024,  takes  effect;
 provided, however, that section two of this act shall take effect on the
 same date and in the same manner as section 2 of chapter 641 of the laws
 of 2024, takes effect.