A04996 Summary:

BILL NO    A04996 

SAME AS    SAME AS S06586

SPONSOR    Gottfried

COSPNSR    Jaffee, 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.
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A04996 Actions:

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
01/08/2014 referred to health
01/14/2014 reported referred to ways and means
04/01/2014 enacting clause stricken
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A04996 Votes:

There are no votes for this bill in this legislative session.
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A04996 Memo:

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.
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A04996 Text:

                           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.
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