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AB1327 Text:

                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________

                                        1327--A
                                                                   R. R. 60

                              2015-2016 Regular Sessions

                                 I N  A S S E M B L Y

                                    January 9, 2015
                                      ___________

       Introduced by M. of A. CAHILL, ABINANTI -- read once and referred to the
         Committee  on  Insurance  -- reported and referred to the Committee on
         Rules -- amended on  the  special  order  of  third  reading,  ordered
         reprinted  as  amended,  retaining  its  place on the special order of
         third reading

       AN ACT to amend the public health law and the insurance law, in relation
         to expedited utilization review of court ordered mental health  and/or
         substance use disorder services

         THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
       BLY, DO ENACT AS FOLLOWS:

    1    Section 1. Subdivision 2 of section 4903 of the public health law,  as
    2  amended  by  section  22 of part H of chapter 60 of the laws of 2014, is
    3  amended to read as follows:
    4    2. (A) A utilization review agent  shall  make  a  utilization  review
    5  determination  involving health care services which require pre-authori-
    6  zation and  provide  notice  of  a  determination  to  the  enrollee  or
    7  enrollee's designee and the enrollee's health care provider by telephone
    8  and  in  writing  within three business days of receipt of the necessary
    9  information. To the extent practicable, such written notification to the
   10  enrollee's health care provider shall be transmitted electronically,  in
   11  a  manner  and  in  a form agreed upon by the parties.  The notification
   12  shall identify; [(a)] (I) whether the services are considered in-network
   13  or out-of-network; [(b)] (II) and whether  the  enrollee  will  be  held
   14  harmless  for the services and not be responsible for any payment, other
   15  than any applicable co-payment or co-insurance; [(c)] (III) as  applica-
   16  ble,  the  dollar amount the health care plan will pay if the service is
   17  out-of-network; and [(d)] (IV) as applicable, information explaining how
   18  an enrollee may determine the anticipated out-of-pocket cost for out-of-
   19  network health care services in a geographical area or  zip  code  based
   20  upon the difference between what the health care plan will reimburse for

        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD06406-05-5
       A. 1327--A                          2

    1  out-of-network health care services and the usual and customary cost for
    2  out-of-network health care services.
    3    (B)  WITH  REGARD TO INDIVIDUAL OR GROUP CONTRACTS AUTHORIZED PURSUANT
    4  TO ARTICLE FORTY-FOUR OF THIS CHAPTER, FOR UTILIZATION  REVIEW  DETERMI-
    5  NATIONS  INVOLVING  PROPOSED MENTAL HEALTH AND/OR SUBSTANCE USE DISORDER
    6  SERVICES WHERE THE ENROLLEE OR THE ENROLLEE'S DESIGNEE HAS, IN A  FORMAT
    7  PRESCRIBED BY THE SUPERINTENDENT OF FINANCIAL SERVICES, CERTIFIED IN THE
    8  REQUEST  THAT  THE  PROPOSED  SERVICES ARE FOR AN INDIVIDUAL WHO WILL BE
    9  APPEARING, OR HAS APPEARED, BEFORE A COURT OF COMPETENT JURISDICTION AND
   10  MAY BE SUBJECT TO A COURT ORDER REQUIRING SUCH SERVICES, THE UTILIZATION
   11  REVIEW AGENT SHALL MAKE A  DETERMINATION  AND  PROVIDE  NOTICE  OF  SUCH
   12  DETERMINATION  TO  THE  ENROLLEE OR THE ENROLLEE'S DESIGNEE BY TELEPHONE
   13  WITHIN SEVENTY-TWO HOURS OF RECEIPT OF THE REQUEST.  WRITTEN  NOTICE  OF
   14  THE  DETERMINATION  TO  THE ENROLLEE OR ENROLLEE'S DESIGNEE SHALL FOLLOW
   15  WITHIN THREE BUSINESS DAYS. WHERE FEASIBLE, SUCH TELEPHONIC AND  WRITTEN
   16  NOTICE SHALL ALSO BE PROVIDED TO THE COURT.
   17    S  2.  Subdivision  2  of  section  4904  of the public health law, as
   18  amended by chapter 41 of the  laws  of  2014,  is  amended  to  read  as
   19  follows:
   20    2.  A  utilization  review  agent  shall establish an expedited appeal
   21  process for appeal of an adverse determination involving:
   22    (a) continued or extended health care services, procedures  or  treat-
   23  ments  or  additional  services  for  an enrollee undergoing a course of
   24  continued treatment prescribed by a health  care  provider  home  health
   25  care  services  following discharge from an inpatient hospital admission
   26  pursuant to subdivision three of section  forty-nine  hundred  three  of
   27  this [article] TITLE; or
   28    (b)  an  adverse  determination  in  which  the  health  care provider
   29  believes an immediate  appeal  is  warranted  except  any  retrospective
   30  determination[.]; OR
   31    (C)  POTENTIAL COURT-ORDERED MENTAL HEALTH AND/OR SUBSTANCE USE DISOR-
   32  DER SERVICES PURSUANT TO PARAGRAPH (B) OF  SUBDIVISION  TWO  OF  SECTION
   33  FORTY-NINE HUNDRED THREE OF THIS TITLE. Such process shall include mech-
   34  anisms  which  facilitate  resolution  of  the  appeal including but not
   35  limited to the sharing of information from the  enrollee's  health  care
   36  provider  and  the  utilization  review  agent by telephonic means or by
   37  facsimile. The utilization review agent shall provide reasonable  access
   38  to  its  clinical  peer  reviewer  within  one business day of receiving
   39  notice of the taking of an expedited appeal.  Expedited appeals shall be
   40  determined within two business days of receipt of necessary  information
   41  to  conduct  such appeal except, with respect to inpatient substance use
   42  disorder treatment provided pursuant to paragraph (c) of subdivision [3]
   43  THREE of section [four thousand nine] FORTY-NINE hundred three  of  this
   44  [article]  TITLE,  expedited  appeals shall be determined within twenty-
   45  four hours of receipt of such appeal. Expedited  appeals  which  do  not
   46  result  in  a  resolution  satisfactory  to  the  appealing party may be
   47  further appealed through the standard appeal  process,  or  through  the
   48  external  appeal process pursuant to section forty-nine hundred fourteen
   49  of this article  as  applicable.  Provided  that  the  enrollee  or  the
   50  enrollee's health care provider files an expedited internal and external
   51  appeal within twenty-four hours from receipt of an adverse determination
   52  for  inpatient  substance  use disorder treatment for which coverage was
   53  provided while the initial utilization review determination was  pending
   54  pursuant  to  paragraph  (c)  of  subdivision [3] THREE of section [four
   55  thousand nine] FORTY-NINE hundred  three  of  this  [article]  TITLE,  a
   56  utilization review agent shall not deny on the basis of medical necessi-
       A. 1327--A                          3

    1  ty  or lack of prior authorization such substance use disorder treatment
    2  while a determination by the utilization review agent or external appeal
    3  agent is pending.
    4    S  3.  Subsection (b) of section 4903 of the insurance law, as amended
    5  by section 12 of part H of chapter 60 of the laws of 2014, is amended to
    6  read as follows:
    7    (b) (1) A utilization review agent shall  make  a  utilization  review
    8  determination  involving health care services which require pre-authori-
    9  zation and provide notice of a determination to the insured or insured's
   10  designee and the insured's health care  provider  by  telephone  and  in
   11  writing  within three business days of receipt of the necessary informa-
   12  tion. To the  extent  practicable,  such  written  notification  to  the
   13  enrollee's  health care provider shall be transmitted electronically, in
   14  a manner and in a form agreed upon by the  parties.    The  notification
   15  shall identify: [(1)] (I) whether the services are considered in-network
   16  or  out-of-network; [(2)] (II) whether the insured will be held harmless
   17  for the services and not be responsible for any payment, other than  any
   18  applicable co-payment, co-insurance or deductible; [(3)] (III) as appli-
   19  cable, the dollar amount the health care plan will pay if the service is
   20  out-of-network; and [(4)] (IV) as applicable, information explaining how
   21  an  insured may determine the anticipated out-of-pocket cost for out-of-
   22  network health care services in a geographical area or  zip  code  based
   23  upon the difference between what the health care plan will reimburse for
   24  out-of-network health care services and the usual and customary cost for
   25  out-of-network health care services.
   26    (2)  WITH  REGARD TO INDIVIDUAL OR GROUP CONTRACTS AUTHORIZED PURSUANT
   27  TO ARTICLE THIRTY-TWO, FORTY-THREE OR FORTY-SEVEN  OF  THIS  CHAPTER  OR
   28  ARTICLE  FORTY-FOUR OF THE PUBLIC HEALTH LAW, FOR UTILIZATION AND REVIEW
   29  DETERMINATIONS INVOLVING PROPOSED MENTAL  HEALTH  AND/OR  SUBSTANCE  USE
   30  DISORDER  SERVICES WHERE THE INSURED OR THE INSURED'S DESIGNEE HAS, IN A
   31  FORMAT PRESCRIBED BY THE SUPERINTENDENT, CERTIFIED IN THE  REQUEST  THAT
   32  THE  PROPOSED  SERVICES  ARE FOR AN INDIVIDUAL WHO WILL BE APPEARING, OR
   33  HAS APPEARED, BEFORE A  COURT  OF  COMPETENT  JURISDICTION  AND  MAY  BE
   34  SUBJECT TO A COURT ORDER REQUIRING SUCH SERVICES, THE UTILIZATION REVIEW
   35  AGENT  SHALL  MAKE  A  DETERMINATION AND PROVIDE NOTICE OF SUCH DETERMI-
   36  NATION TO THE INSURED OR THE  INSURED'S  DESIGNEE  BY  TELEPHONE  WITHIN
   37  SEVENTY-TWO  HOURS  OF  RECEIPT  OF  THE  REQUEST. WRITTEN NOTICE OF THE
   38  DETERMINATION TO THE INSURED OR INSURED'S DESIGNEE SHALL  FOLLOW  WITHIN
   39  THREE  BUSINESS DAYS. WHERE FEASIBLE, SUCH TELEPHONIC AND WRITTEN NOTICE
   40  SHALL ALSO BE PROVIDED TO THE COURT.
   41    S 4. Subsection (b) of section 4904 of the insurance law,  as  amended
   42  by chapter 41 of the laws of 2014, is amended to read as follows:
   43    (b)  A  utilization  review  agent shall establish an expedited appeal
   44  process for appeal of an adverse determination involving  (1)  continued
   45  or extended health care services, procedures or treatments or additional
   46  services  for  an  insured  undergoing  a  course of continued treatment
   47  prescribed by a health  care  provider  or  home  health  care  services
   48  following  discharge  from  an  inpatient hospital admission pursuant to
   49  subsection (c) of section four  thousand  nine  hundred  three  of  this
   50  [article  or]  TITLE;  (2)  an adverse determination in which the health
   51  care provider believes an  immediate  appeal  is  warranted  except  any
   52  retrospective  determination;  OR  (3)  POTENTIAL  COURT-ORDERED  MENTAL
   53  HEALTH AND/OR SUBSTANCE USE DISORDER SERVICES PURSUANT TO PARAGRAPH  TWO
   54  OF  SUBSECTION  (B)  OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS
   55  TITLE. Such process shall include mechanisms which facilitate resolution
   56  of the appeal including but not limited to the  sharing  of  information
       A. 1327--A                          4

    1  from the insured's health care provider and the utilization review agent
    2  by  telephonic means or by facsimile. The utilization review agent shall
    3  provide reasonable access to its clinical peer reviewer within one busi-
    4  ness day of receiving notice of the taking of an expedited appeal. Expe-
    5  dited appeals shall be determined within two business days of receipt of
    6  necessary  information  to  conduct  such appeal except, with respect to
    7  inpatient substance use disorder treatment provided  pursuant  to  para-
    8  graph  three  of  subsection  (c)  of section four thousand nine hundred
    9  three of this [article] TITLE, expedited  appeals  shall  be  determined
   10  within  twenty-four  hours  of receipt of such appeal. Expedited appeals
   11  which do not result in a resolution satisfactory to the appealing  party
   12  may  be further appealed through the standard appeal process, or through
   13  the external appeal process  pursuant  to  section  four  thousand  nine
   14  hundred  fourteen  of  this  article  as  applicable.  Provided that the
   15  insured or the insured's health care provider files an expedited  inter-
   16  nal  and  external  appeal  within  twenty-four hours from receipt of an
   17  adverse determination for inpatient substance use disorder treatment for
   18  which coverage was provided while the initial utilization review  deter-
   19  mination  was  pending  pursuant to paragraph three of subsection (c) of
   20  section four thousand nine hundred three  of  this  [article]  TITLE,  a
   21  utilization review agent shall not deny on the basis of medical necessi-
   22  ty  or lack of prior authorization such substance use disorder treatment
   23  while a determination by the utilization review agent or external appeal
   24  agent is pending.
   25    S 5. This act shall take effect April 1, 2016 and shall apply to poli-
   26  cies issued, renewed, or modified on and after such date.
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