BILL NO A04996
SAME AS No same as
SPONSOR Gottfried
COSPNSR Jaffee, Maisel, Millman, Clark, Hevesi, Rosenthal
MLTSPNSR Fahy, Jacobs, Lentol, McDonald, Perry, Schimel
Amd SS22 & 365-a, Soc Serv L, amd S4403-f, Pub Health L
Provides that enrollees are not required to exhaust Medicaid appeals prior to
requesting a fair hearing.
BILL NO A04996
02/14/2013 referred to health
04/16/2013 reported referred to ways and means
06/03/2013 reported referred to rules
06/10/2013 reported
06/10/2013 rules report cal.108
06/10/2013 ordered to third reading rules cal.108
BILL NUMBER:A4996
TITLE OF BILL: An act to amend the social services law and the public
health law, in relation to medicaid reviews and appeals
PURPOSE OR GENERAL IDEA OF BILL: To clarify that Medicaid enrollees
who have been denied services by a Medicaid managed care plan may file
for a fair hearing under the Social Services Law as well as internal
and external appeal under managed care laws, and are entitled to the
continuation of services as usual while appeals and fair hearings
proceed.
SUMMARY OF SPECIFIC PROVISIONS: The bill amends Social Services Law
22 and Public Health Law S 4403-F to assure that Medicaid enrollees do
not have to exhaust internal and external appeals of managed care plan
adverse determinations in order to proceed with Medicaid fair
hearings. The bill amends Social Services Law S 265-a to clarify that
health care services continue until the appeal(s) is resolved.
JUSTIFICATION: Medicaid recipients are increasingly moved into managed
care plans subject to the managed care internal and external appeal
processes.. This is being used to assert that the recipients may not
file for a Social Services Law fair hearing until those managed care
appeals are exhausted. Unfortunately, this has the effect of depriving
recipients of their longstanding right to have services continue while
a fair hearing appeal is pending. This can have the effect of
depriving people of health care services to which they are legally
entitle.
This bill will assure that the remedies of managed care benefits
appeals are cumulative to Medicaid fair hearing rights and that health
care services once determined to be medically necessary are not
threatened by bureaucratic delays in either appeal process.
PRIOR LEGISLATIVE HISTORY: New bill
FISCAL IMPLICATIONS: None
EFFECTIVE DATE: Immediately and apply to any appeal pending at the
time.
S T A T E O F N E W Y O R K
________________________________________________________________________
4996
2013-2014 Regular Sessions
I N A S S E M B L Y
February 14, 2013
___________
Introduced by M. of A. GOTTFRIED -- read once and referred to the
Committee on Health
AN ACT to amend the social services law and the public health law, in
relation to medicaid reviews and appeals
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Section 22 of the social services law is amended by adding
2 a new subdivision 15 to read as follows:
3 15. WITH RESPECT TO MEDICAL ASSISTANCE UNDER TITLE ELEVEN OF ARTICLE
4 FIVE OF THIS CHAPTER, WHERE THE MEDICAL SERVICE AT ISSUE IS OR WOULD BE
5 PROVIDED BY AN ENTITY SUBJECT TO ARTICLE FORTY-NINE OF THE PUBLIC HEALTH
6 LAW OR ARTICLE FORTY-NINE OF THE INSURANCE LAW:
7 1. AN ENROLLEE SHALL NOT BE REQUIRED TO EXHAUST HIS OR HER REVIEW OR
8 APPEAL REMEDIES UNDER ARTICLE FORTY-NINE OF THE PUBLIC HEALTH LAW OR
9 ARTICLE FORTY-NINE OF THE INSURANCE LAW PRIOR TO REQUESTING A FAIR HEAR-
10 ING UNDER THIS SECTION OR ANY OTHER STATE OR FEDERAL LAW. HOWEVER, IN AN
11 APPROPRIATE CASE, THE HOLDING OR CONTINUING OF THE FAIR HEARING MAY BE
12 DELAYED PENDING THE OUTCOME OF SUCH REVIEW OR APPEAL.
13 2. THE RIGHTS AND REMEDIES CONFERRED UNDER THOSE PROVISIONS OF THE
14 PUBLIC HEALTH LAW OR THE INSURANCE LAW SHALL BE CUMULATIVE AND IN ADDI-
15 TION TO AND NOT IN LIEU OF ANY OTHER RIGHTS OR REMEDIES AVAILABLE UNDER
16 LAW.
17 S 2. Subdivision 8 of section 365-a of the social services law, as
18 added by section 46-a of part B of chapter 58 of the laws of 2009, is
19 amended to read as follows:
20 8. When a non-governmental entity is authorized by the department
21 pursuant to contract or subcontract to make prior authorization or prior
22 approval determinations that may be required for any item of medical
23 assistance, a recipient may challenge any action taken or failure to act
24 in connection with a prior authorization or prior approval determination
25 as if such determination were made by a government entity, and shall be
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD08746-01-3
A. 4996 2
1 entitled to the same medical assistance benefits and standards and to
2 the same notice and procedural due process rights, including a right to
3 a fair hearing and aid continuing pursuant to section twenty-two of this
4 chapter, as if the prior authorization or prior approval determination
5 were made by a government entity, WITHOUT REGARD TO EXPIRATION OF THE
6 PRIOR SERVICE AUTHORIZATION.
7 S 3. Subparagraph (ii) of paragraph (a) of subdivision 7 of section
8 4403-f of the public health law, as amended by section 41-b of part H of
9 chapter 59 of the laws of 2011, is amended to read as follows:
10 (ii) Notwithstanding any inconsistent provision of the social services
11 law to the contrary, the commissioner shall, pursuant to regulation,
12 determine whether and the extent to which the applicable provisions of
13 the social services law or regulations relating to approvals and author-
14 izations of, and utilization limitations on, health and long term care
15 services reimbursed pursuant to title XIX of the federal social security
16 act, including, but not limited to, fiscal assessment requirements, are
17 inconsistent with the flexibility necessary for the efficient adminis-
18 tration of managed long term care plans and such regulations shall
19 provide that such provisions shall not be applicable to enrollees or
20 managed long term care plans, provided that such determinations are
21 consistent with applicable federal law and regulation, AND SUBJECT TO
22 THE PROVISIONS OF SUBDIVISION EIGHT OF SECTION THREE HUNDRED
23 SIXTY-FIVE-A OF THE SOCIAL SERVICES LAW.
24 S 4. This act shall take effect immediately and shall apply to any
25 review or appeal under the social services law, public health law or
26 insurance law pending at the time it becomes a law; provided, however,
27 that the amendments to section 4403-f of the public health law made by
28 section three of this act shall not affect the repeal of such section
29 and shall be deemed repealed therewith.
