Provides 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.
STATE OF NEW YORK
________________________________________________________________________
4063
2025-2026 Regular Sessions
IN ASSEMBLY
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:
1 Section 1. Subdivision 7 of section 4903 of the public health law, as
2 amended by chapter 641 of the laws of 2024, is amended to read as
3 follows:
4 7. Failure by the utilization review agent to make a determination
5 within the time periods prescribed in this section shall be deemed to be
6 an [adverse determination subject to appeal pursuant to section forty-
7 nine hundred four of this title, provided, however, that] approval of
8 the health care services in question and failure to meet such time peri-
9 ods for a step therapy protocol as defined in subdivision seven-f-three
10 of section forty-nine hundred of this title or a step therapy protocol
11 override determination pursuant to subdivisions three-a, three-b and
12 three-c of this section shall be deemed to be an override of the step
13 therapy protocol. A utilization review agent's failure to comply with
14 any of the step therapy protocol requirements required in subdivisions
15 five and six of section forty-nine hundred two of this title shall be
16 considered a basis for granting an override of the step therapy proto-
17 col, absent fraud.
18 § 2. Subsection (g) of section 4903 of the insurance law, as amended
19 by chapter 641 of the laws of 2024, is amended to read as follows:
20 (g) Failure by the utilization review agent to make a determination
21 within the time periods prescribed in this section shall be deemed to be
22 an [adverse determination subject to appeal pursuant to section four
23 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
1 of the health care services in question and that failure to meet such
2 time periods for a step therapy protocol as defined in subsection (g-9)
3 of section forty-nine hundred of this title or a step therapy protocol
4 override determination pursuant to subsections (c-1), (c-2) and (c-3) of
5 this section shall be deemed to be an override of the step therapy
6 protocol. A utilization review agent's failure to comply with any of the
7 step therapy protocol requirements required in [subsections] paragraphs
8 fifteen and sixteen of subsection (a) of section four thousand nine
9 hundred two of this title shall be considered a basis for granting an
10 override of the step therapy protocol, absent fraud.
11 § 3. This act shall take effect on the same date and in the same
12 manner as section 4 of chapter 641 of the laws of 2024, takes effect;
13 provided, however, that section two of this act shall take effect on the
14 same date and in the same manner as section 2 of chapter 641 of the laws
15 of 2024, takes effect.
