Provides that a utilization review agent shall not issue an adverse determination denying, reducing, or terminating coverage for medically necessary skilled rehabilitation services solely because the insured or enrollee has failed to demonstrate measurable improvement in the insured's or enrollee's condition.
STATE OF NEW YORK
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11673
IN ASSEMBLY
September 2, 2026
___________
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Weprin) --
read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to prohibiting the termi-
nation of coverage for rehabilitation services solely because of a
failure to demonstrate measurable improvement in the applicable condi-
tion
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Section 4903 of the insurance law is amended by adding a
2 new subsection (j) to read as follows:
3 (j) (1) A utilization review agent shall not issue an adverse determi-
4 nation denying, reducing, or terminating coverage for medically neces-
5 sary skilled rehabilitation services solely because the insured or
6 enrollee has failed to demonstrate measurable improvement in the
7 insured's or enrollee's condition.
8 (2) For purposes of this subsection, medically necessary skilled reha-
9 bilitation services may include physical therapy, occupational therapy,
10 speech-language pathology services, pulmonary rehabilitation, cardiac
11 rehabilitation, and other rehabilitative services performed by a
12 licensed health care professional acting within the scope of their prac-
13 tice.
14 (3) A utilization review agent shall consider whether continued
15 skilled services are reasonably expected to:
16 (i) maintain the insured's or enrollee's current level of function;
17 (ii) prevent or slow deterioration in functional capacity;
18 (iii) reduce pain or other symptoms that impair activities of daily
19 living;
20 (iv) prevent hospitalization, institutionalization, surgery, or other
21 more intensive medical intervention; or
22 (v) permit the safe performance of a maintenance program requiring the
23 specialized clinical judgment or skills of a licensed health care
24 professional.
25 (4) An adverse determination shall not be based solely upon a finding
26 that the insured or enrollee has reached a plateau, has failed to demon-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD16271-01-6
A. 11673 2
1 strate objective improvement, or has a chronic, progressive, or degener-
2 ative condition.
3 (5) Nothing in this subsection shall be construed to require coverage
4 for services that are not otherwise medically necessary or that do not
5 require the specialized knowledge, clinical judgment, or skills of a
6 licensed health care professional.
7 § 2. This act shall take effect immediately.
