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A00728 Summary:

A00728 Actions:

A00728 Floor Votes:

A00728 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         728--A
                                                                 Cal. No. 63
 
                               2009-2010 Regular Sessions
 
                   IN ASSEMBLY
 
                                       (Prefiled)
 
                                     January 7, 2009
                                       ___________
 
        Introduced  by  M.  of A. GOTTFRIED, CANESTRARI, DINOWITZ, JACOBS, JOHN,
          PAULIN, KAVANAGH, SCARBOROUGH  --  Multi-Sponsored  by  --  M.  of  A.
          ABBATE, AUBRY, BING, BRENNAN, CLARK, COLTON, COOK, CUSICK, CYMBROWITZ,

          ENGLEBRIGHT,  GALEF,  GLICK,  HEASTIE, HOOPER, KELLNER, LIFTON, MAYER-
          SOHN,  McENENY,  MILLMAN,  ORTIZ,  PEOPLES-STOKES,   PERRY,   PHEFFER,
          J. RIVERA,  ROBINSON,  SWEENEY,  TOWNS,  WEISENBERG  --  read once and
          referred to the  Committee  on  Health  --  reported  from  committee,
          advanced  to a third reading, amended and ordered reprinted, retaining
          its place on the order of third reading
 
        AN ACT to amend the public health law and the insurance law, in relation
          to notification of an enrollee's designee and  the  enrollee's  health
          care  provider  of the initiation of an external appeal and the appeal
          determination; and to repeal certain provisions of the  public  health
          law  and  the  insurance  law allowing a health care plan to charge an
          insured a fee for an appeal
 
          The People of the State of New York, represented in Senate and  Assem-

        bly, do enact as follows:
 
     1    Section  1.  Subdivision 3 of section 4910 of the public health law is
     2  REPEALED.
     3    § 2. Paragraphs (a) and (b) of subdivision 2 of section  4914  of  the
     4  public  health law, paragraph (a) as added by chapter 586 of the laws of
     5  1998 and paragraph (b) as amended by chapter 237 of the  laws  of  2009,
     6  are amended to read as follows:
     7    (a)  The  enrollee  shall have forty-five days to initiate an external
     8  appeal after the enrollee [receives], the enrollee's designee,  if  any,
     9  and  the enrollee's health care provider, receive notice from the health
    10  care plan, or such plan's utilization review agent if applicable,  of  a
    11  final  adverse  determination  or  denial or after both the plan and the
    12  enrollee have jointly agreed to waive any internal appeal. Such  request

    13  shall be in writing in accordance with the instructions and in such form
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD00977-02-0
        A. 728--A                           2
 
     1  prescribed  by  subdivision five of this section.  The enrollee, and the
     2  enrollee's health care provider where applicable, shall have the  oppor-
     3  tunity to submit additional documentation with respect to such appeal to
     4  the  external  appeal  agent within such forty-five-day period; provided
     5  however that when such documentation represents a material  change  from
     6  the  documentation  upon  which  the  utilization review agent based its
     7  adverse determination or upon which the health plan  based  its  denial,

     8  the health plan shall have three business days to consider such documen-
     9  tation and amend or confirm such adverse determination.
    10    (b)  The external appeal agent shall make a determination with respect
    11  to the appeal within thirty days of the receipt of the request therefor,
    12  submitted  in  accordance  with  the  commissioner's  instructions.  The
    13  external  appeal  agent shall have the opportunity to request additional
    14  information from the enrollee, the enrollee's health care  provider  and
    15  the  enrollee's health care plan within such thirty-day period, in which
    16  case the agent shall have up to five additional business days if  neces-
    17  sary  to make such determination. The external appeal agent shall notify
    18  the enrollee, the enrollee's designee, if  any,  the  enrollee's  health
    19  care  provider  where appropriate, and the health care plan, in writing,

    20  of the appeal determination within two business days of the rendering of
    21  such determination.
    22    § 3. Subsection (c) of section 4910 of the insurance law is REPEALED.
    23    § 4. Paragraphs 1 and 2 of subsection  (b)  of  section  4914  of  the
    24  insurance  law,  paragraph 1 as added by chapter 586 of the laws of 1998
    25  and paragraph 2 as amended by chapter 237  of  the  laws  of  2009,  are
    26  amended to read as follows:
    27    (1)  The  insured  shall  have forty-five days to initiate an external
    28  appeal after the insured [receives], the insured's designee, if any, and
    29  the insured's health care provider, receive notice from the health  care
    30  plan,  or such plan's utilization review agent if applicable, of a final
    31  adverse determination or denial or after both the plan and the  enrollee

    32  have  jointly agreed to waive any internal appeal. Such request shall be
    33  in writing  in  accordance  with  the  instructions  and  in  such  form
    34  prescribed  by  subsection  (e)  of this section.   The insured, and the
    35  insured's health care provider where applicable, shall have the opportu-
    36  nity to submit additional documentation with respect to such  appeal  to
    37  the  external  appeal  agent within such forty-five-day period; provided
    38  however that when such documentation represents a material  change  from
    39  the  documentation  upon  which  the  utilization review agent based its
    40  adverse determination or upon which the health plan  based  its  denial,
    41  the health plan shall have three business days to consider such documen-
    42  tation and amend or confirm such adverse determination.
    43    (2)  The  external appeal agent shall make a determination with regard

    44  to the appeal within thirty days of the receipt of the request therefor,
    45  submitted in accordance  with  the  superintendent's  instructions.  The
    46  external  appeal  agent shall have the opportunity to request additional
    47  information from the insured, the insured's health care provider and the
    48  insured's health care plan within such thirty-day period, in which  case
    49  the agent shall have up to five additional business days if necessary to
    50  make  such  determination.  The  external  appeal agent shall notify the
    51  insured, the insured's designee,  if  any,  the  insured's  health  care
    52  provider where appropriate, and the health care plan, in writing, of the
    53  appeal  determination  within two business days of the rendering of such
    54  determination.
    55    § 5. This act shall take effect on the one hundred eightieth day after
    56  it shall become a law.

        A. 728--A                           3
 
          REPEAL NOTE.--Subdivision 3 of section 4910 of the public  health  law
        repealed  by  section one of this act and subsection (c) of section 4910
        of the insurance law repealed by section three of this act,  allows  the
        health  care  plan to charge an insured a fee of up to fifty dollars per
        external appeal.