Senate Bill S9651

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   9651
 
                             I N  S E N A T E
 
                              March 31, 2026
                                ___________
 
 Introduced  by  Sen.  RIVERA -- read twice and ordered printed, and when
   printed to be committed to the Committee on Health
 
 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
 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
 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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD07503-01-5
 S. 9651                             2
 
 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.
   § 5. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.