Directs a health maintenance organization which denies a claim due to absence of medical necessity to inform the insured as to preferred alternative treatment, or provide the insured with a statement as to the past ineffectiveness of the requested procedure or treatment.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A4772
SPONSOR: Pretlow PURPOSE OR GENERAL IDEA OF BILL:
This bill would amend the Insurance Law to require health maintenance
organizations to furnish an insured client, upon denial of coverage for
a requested treatment or procedure, with either a list of alternative
treatments that would be covered or a statement detailing the past inef-
fectiveness of the requested treatment or procedure.
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 amends the Insurance Law by adding a new Section 2601-a, which
directs health maintenance organizations to inform an insured customer
of the preferred procedures or treatment options which would be covered
or a statement detailing the past ineffectiveness of the requested
procedure or treatment. Section two establishes an effective date.
JUSTIFICATION:
Insured individuals seeking care for a medical condition are sometimes
denied coverage for a particular procedure or treatment because it is
deemed medically unnecessary by an insurer. Currently, an insurer is
under no obligation to inform the insured about the past ineffectiveness
of the requested procedure or treatment which was the reason for its
denial. Nor is an insurer obliged to provide the insured with a list of
alternative procedures that would both address the medical condition and
be covered by the insurer. This lack of information may lead some indi-
viduals to abandon efforts to pursue other treatment options, possibly
exacerbating their current health condition. This bill would direct
insurers to inform patients why the requested coverage was denied or
which alternative treatments would be covered. This legislation would
ensure that patients are not inadvertently discouraged from seeking
appropriate medical care that is covered by their health insurance.
PRIOR LEGISLATIVE HISTORY:
A1825 2021-2022 referred to insurance
A4103 2019-2020 referred to insurance A766 01/09/17 referred to insur-
ance A766 01/03/18 referred to insurance
FISCAL IMPLICATIONS:
None.
EFFECTIVE DATE:
This act shall take effect in 30 days.
STATE OF NEW YORK
________________________________________________________________________
4772
2023-2024 Regular Sessions
IN ASSEMBLY
February 23, 2023
___________
Introduced by M. of A. PRETLOW -- read once and referred to the Commit-
tee on Insurance
AN ACT to amend the insurance law, in relation to notice by health main-
tenance organizations that a request for coverage of a particular
treatment is denied
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. The insurance law is amended by adding a new section 2601-a
2 to read as follows:
3 § 2601-a. Denial of coverage or treatment by a health maintenance
4 organization. Whenever a health maintenance organization, doing business
5 in this state, denies a claim for coverage of a particular procedure or
6 treatment because such procedure or treatment is not medically neces-
7 sary, the health maintenance organization shall inform the insured as to
8 those preferred procedure or treatment options which would be covered,
9 or provide the insured with a statement as to the past ineffectiveness
10 of the requested procedure or treatment.
11 § 2. This act shall take effect on the thirtieth day after it shall
12 have become a law.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD09492-01-3
