Amd §§4902 & 4903, Pub Health L; amd §§4902, 4903 & 3238, Ins L
Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; relates to prescription drug formulary changes and pre-authorization for certain health care services.
STATE OF NEW YORK
________________________________________________________________________
7129--A
2021-2022 Regular Sessions
IN ASSEMBLY
April 23, 2021
___________
Introduced by M. of A. GOTTFRIED, WOERNER, TAYLOR, SANTABARBARA, SOLAG-
ES, COLTON, LUPARDO, MONTESANO, ENGLEBRIGHT, STIRPE, EPSTEIN, THIELE,
PAULIN, WALCZYK, NORRIS, SEAWRIGHT, SIMON, ABINANTI, JOYNER, M. MILL-
ER, LAVINE, STECK, TANNOUSIS -- read once and referred to the Commit-
tee on Insurance -- recommitted to the Committee on Insurance in
accordance with Assembly Rule 3, sec. 2 -- committee discharged, bill
amended, ordered reprinted as amended and recommitted to said commit-
tee
AN ACT to amend the public health law and the insurance law, in relation
to utilization review program standards, and in relation to pre-au-
thorization of health care services
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Paragraph (c) of subdivision 1 of section 4902 of the
2 public health law, as added by chapter 705 of the laws of 1996, is
3 amended to read as follows:
4 (c) Utilization of written clinical review criteria developed pursuant
5 to a utilization review plan. Such clinical review criteria shall
6 utilize recognized evidence-based and peer reviewed clinical review
7 criteria that take into account the needs of a typical patient popu-
8 lations and diagnoses;
9 § 2. Paragraph (a) of subdivision 2 of section 4903 of the public
10 health law, as separately amended by section 13 of part YY and section 3
11 of part KKK of chapter 56 of the laws of 2020, is amended to read as
12 follows:
13 (a) A utilization review agent shall make a utilization review deter-
14 mination involving health care services which require pre-authorization
15 and provide notice of a determination to the enrollee or enrollee's
16 designee and the enrollee's health care provider by telephone and in
17 writing within [three business days] seventy-two hours of receipt of the
18 necessary information, within twenty-four hours of the receipt of neces-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD03897-05-2
A. 7129--A 2
1 sary information if the request is for an enrollee with a medical condi-
2 tion that places the health of the insured in serious jeopardy without
3 the health care services recommended by the enrollee's health care
4 professional, or for inpatient rehabilitation services following an
5 inpatient hospital admission provided by a hospital or skilled nursing
6 facility, within one business day of receipt of the necessary informa-
7 tion. The notification shall identify[;]: (i) whether the services are
8 considered in-network or out-of-network; (ii) and whether the enrollee
9 will be held harmless for the services and not be responsible for any
10 payment, other than any applicable co-payment or co-insurance; (iii) as
11 applicable, the dollar amount the health care plan will pay if the
12 service is out-of-network; and (iv) as applicable, information explain-
13 ing how an enrollee may determine the anticipated out-of-pocket cost for
14 out-of-network health care services in a geographical area or zip code
15 based upon the difference between what the health care plan will reim-
16 burse for out-of-network health care services and the usual and custom-
17 ary cost for out-of-network health care services. An approval for a
18 request for pre-authorization shall be valid for (1) the duration of the
19 prescription, including any authorized refills and (2) the duration of
20 treatment for a specific condition as requested by the enrollee's health
21 care provider.
22 § 3. Paragraph 3 of subsection (a) of section 4902 of the insurance
23 law, as added by chapter 705 of the laws of 1996, is amended to read as
24 follows:
25 (3) Utilization of written clinical review criteria developed pursuant
26 to a utilization review plan. Such clinical review criteria shall
27 utilize recognized evidence-based and peer reviewed clinical review
28 criteria that take into account the needs of a typical patient popu-
29 lations and diagnoses;
30 § 4. Paragraph 1 of subsection (b) of section 4903 of the insurance
31 law, as separately amended by section 16 of part YY and section 7 of
32 part KKK of chapter 56 of the laws of 2020, is amended to read as
33 follows:
34 (1) A utilization review agent shall make a utilization review deter-
35 mination involving health care services which require pre-authorization
36 and provide notice of a determination to the insured or insured's desig-
37 nee and the insured's health care provider by telephone and in writing
38 within [three business days] seventy-two hours of receipt of the neces-
39 sary information, within twenty-four hours of receipt of necessary
40 information if the request is for an insured with a medical condition
41 that places the health of the insured in serious jeopardy without the
42 health care services recommended by the insured's health care provider,
43 or for inpatient rehabilitation services following an inpatient hospital
44 admission provided by a hospital or skilled nursing facility, within one
45 business day of receipt of the necessary information. The notification
46 shall identify: (i) whether the services are considered in-network or
47 out-of-network; (ii) whether the insured will be held harmless for the
48 services and not be responsible for any payment, other than any applica-
49 ble co-payment, co-insurance or deductible; (iii) as applicable, the
50 dollar amount the health care plan will pay if the service is out-of-
51 network; and (iv) as applicable, information explaining how an insured
52 may determine the anticipated out-of-pocket cost for out-of-network
53 health care services in a geographical area or zip code based upon the
54 difference between what the health care plan will reimburse for out-of-
55 network health care services and the usual and customary cost for out-
56 of-network health care services. An approval of request for pre-authori-
A. 7129--A 3
1 zation shall be valid for (1) the duration of the prescription,
2 including any authorized refills and (2) the duration of treatment for a
3 specific condition requested for pre-authorization.
4 § 5. Subsection (a) of section 3238 of the insurance law, as added by
5 chapter 451 of the laws of 2007, is amended to read as follows:
6 (a) An insurer, corporation organized pursuant to article forty-three
7 of this chapter, municipal cooperative health benefits plan certified
8 pursuant to article forty-seven of this chapter, or health maintenance
9 organization and other organizations certified pursuant to article
10 forty-four of the public health law ("health plan") shall pay claims for
11 a health care service for which a pre-authorization was required by, and
12 received from, the health plan prior to the rendering of such health
13 care service, and eligibility confirmed on the day of the service,
14 unless:
15 (1) [(i) the insured, subscriber, or enrollee was not a covered person
16 at the time the health care service was rendered.
17 (ii) Notwithstanding the provisions of subparagraph (i) of this para-
18 graph, a health plan shall not deny a claim on this basis if the
19 insured's, subscriber's or enrollee's coverage was retroactively termi-
20 nated more than one hundred twenty days after the date of the health
21 care service, provided that the claim is submitted within ninety days
22 after the date of the health care service. If the claim is submitted
23 more than ninety days after the date of the health care service, the
24 health plan shall have thirty days after the claim is received to deny
25 the claim on the basis that the insured, subscriber or enrollee was not
26 a covered person on the date of the health care service.
27 (2)] the submission of the claim with respect to an insured, subscrib-
28 er or enrollee was not timely under the terms of the applicable provider
29 contract, if the claim is submitted by a provider, or the policy or
30 contract, if the claim is submitted by the insured, subscriber or enrol-
31 lee;
32 [(3)] (2) at the time the pre-authorization was issued, the insured,
33 subscriber or enrollee had not exhausted contract or policy benefit
34 limitations based on information available to the health plan at such
35 time, but subsequently exhausted contract or policy benefit limitations
36 after authorization was issued; provided, however, that the health plan
37 shall include in the notice of determination required pursuant to
38 subsection (b) of section four thousand nine hundred three of this chap-
39 ter and subdivision two of section forty-nine hundred three of the
40 public health law that the visits authorized might exceed the limits of
41 the contract or policy and accordingly would not be covered under the
42 contract or policy;
43 [(4)] (3) the pre-authorization was based on materially inaccurate or
44 incomplete information provided by the insured, subscriber or enrollee,
45 the designee of the insured, subscriber or enrollee, or the health care
46 provider such that if the correct or complete information had been
47 provided, such pre-authorization would not have been granted; or
48 [(5) the pre-authorized service was related to a pre-existing condi-
49 tion that was excluded from coverage; or
50 (6)] (4) there is a reasonable basis supported by specific information
51 available for review by the superintendent that the insured, subscriber
52 or enrollee, the designee of the insured, subscriber or enrollee, or the
53 health care provider has engaged in fraud or abuse.
54 § 6. This act shall take effect on the ninetieth day after it shall
55 have become a law.
