STATE OF NEW YORK
________________________________________________________________________
10268
IN SENATE
May 11, 2026
___________
Introduced by Sen. SKOUFIS -- read twice and ordered printed, and when
printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law and the public health law, in relation
to requiring insurers and health plans to grant automatic preauthori-
zation approvals to eligible health care professionals in certain
circumstances
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subsection (a) of section 4902 of the insurance law is
2 amended by adding a new paragraph 17 to read as follows:
3 (17) Establishment of automatic preauthorization approval requirements
4 for insurers to provide to health care professionals providing health
5 care services which shall include that:
6 (i) an insurer that uses a preauthorization process for health care
7 services shall provide an automatic preauthorization approval to a
8 health care professional for a particular health care service, as
9 defined under this title including but not limited to health care proce-
10 dures, treatments, services, pharmaceutical products, services or dura-
11 ble medical equipment if, in the most recent six-month evaluation peri-
12 od, the insurer has approved not less than ninety percent of the
13 preauthorization requests submitted by such health care professional for
14 the particular health care service. For the purposes of this require-
15 ment, a preauthorization request submitted during the evaluation period
16 shall be considered and counted as a single request and single approval
17 if the request was approved at any point between the date the request
18 was submitted by the health care professional and the final determi-
19 nation by the insurer, including any re-review or appeal process. Each
20 insurer shall complete its initial evaluation and issue its determi-
21 nation to each health care professional in its network no later than one
22 hundred eighty days after the effective date of this paragraph. The
23 automatic preauthorization approval shall become effective two hundred
24 twenty-five days after the effective date of this paragraph;
25 (ii) after the initial evaluation has been completed the insurer shall
26 annually thereafter evaluate whether a health care professional quali-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD01540-02-5
S. 10268 2
1 fies for an automatic preauthorization approval under subparagraph (i)
2 of this paragraph for additional health care services. Each year, the
3 evaluation shall review preauthorization determinations made in the
4 first six months of the year. Each insurer shall issue its determination
5 to each health care professional in its network no later than November
6 fifteenth to be effective January first of the following year;
7 (iii) the insurer may continue the automatic preauthorization approval
8 under subparagraph (i) of this paragraph without evaluating whether the
9 health care professional qualifies for automatic preauthorization
10 approval for a particular evaluation period;
11 (iv) a health care professional shall not be required to request an
12 automatic preauthorization approval to qualify for such approval;
13 (v) a health care professional's automatic preauthorization approval
14 under subparagraph (i) of this paragraph shall remain in effect until
15 the thirtieth calendar day after:
16 (A) the date the insurer notifies the health care professional of the
17 insurer's determination to rescind the automatic preauthorization
18 approval pursuant to subparagraph (vii) of this paragraph if the health
19 care professional does not appeal such determination; or
20 (B) where the health care professional appeals the determination, the
21 date the insurer notifies the health care professional that an independ-
22 ent review organization has affirmed the insurer's determination to
23 rescind the automatic preauthorization approval;
24 (vi) where an insurer does not finalize a rescission determination as
25 specified in subparagraph (vii) of this paragraph, the health care
26 professional shall be considered to have met the criteria to continue to
27 qualify for the automatic preauthorization approval, which shall remain
28 in effect until the following evaluation period;
29 (vii) an insurer may rescind an automatic preauthorization approval
30 under subparagraph (i) of this paragraph only:
31 (A) effective January of each year;
32 (B) if the insurer makes a determination on the basis of a retrospec-
33 tive review as specified in subparagraph (ii) of this paragraph for the
34 most recent evaluation period that less than ninety percent of the
35 claims for the particular health care service met the medical necessity
36 criteria that would have been used by the insurer when conducting preau-
37 thorization review for the particular health care service during the
38 relevant evaluation period; and
39 (C) the insurer complies with all other applicable requirements of
40 this paragraph and the insurer notifies the health care professional not
41 less than thirty calendar days before the proposed rescission is to take
42 effect, together with the sample of claims used to make the determi-
43 nation pursuant to clause (B) of this subparagraph and a plain language
44 explanation of the health care professional's right to appeal such
45 determination and instructions on how to initiate such appeal;
46 (viii) notwithstanding any contrary provision of subparagraph (i) of
47 this paragraph, an insurer may deny an automatic preauthorization
48 approval:
49 (A) if the health care professional does not have the approval at the
50 time of the relevant evaluation period; and
51 (B) the insurer provides the health care professional with actual
52 statistics and data for the relevant preauthorization request evaluation
53 period and detailed information sufficient to demonstrate that the
54 health care professional does not meet the criteria for an automatic
55 preauthorization approval pursuant to subparagraph (i) of this paragraph
56 for the particular health care service;
S. 10268 3
1 (ix) after a final determination or review affirming the rescission or
2 denial of an automatic preauthorization approval for a specific health
3 care service under this paragraph, a health care professional shall be
4 eligible for consideration of such approval for the same health care
5 service after the evaluation period following the evaluation period
6 which formed the basis of the rescission or denial of such approval;
7 (x) the insurer shall, not later than five business days after deter-
8 mining that a health care professional qualifies for an automatic preau-
9 thorization approval pursuant to subparagraph (i) of this paragraph,
10 provide to a health care professional a notice that shall include:
11 (A) a statement that the health care professional qualifies for an
12 automatic preauthorization approval pursuant to this paragraph;
13 (B) a description of the health care services to which such automatic
14 preauthorization applies; and
15 (C) a statement of the duration that such automatic approval shall
16 remain in effect;
17 (xi) when the health care professional submits a preauthorization
18 request for a health care service for which the health care professional
19 qualifies for an automatic preauthorization approval under subparagraph
20 (i) of this paragraph, the insurer shall promptly issue an automatic
21 preauthorization approval for such health care service;
22 (xii) nothing in this paragraph may be construed to:
23 (A) authorize a health care professional to provide a health care
24 service outside the scope of such health care professional's applicable
25 license; or
26 (B) prohibit a health insurer from performing a retrospective review
27 of the health care service pursuant to section forty-nine hundred three
28 of this title;
29 (xiii) when a health care professional provides a health care service
30 covered by the health care professional's automatic preauthorization
31 approval, the service is deemed medically necessary by virtue of the
32 automatic preauthorization approval. For every claim submitted by a
33 health care professional for such service, each insurer shall promptly
34 pay the full payment to the health care professional. An insurer is
35 prohibited from denying, withholding, or reducing payment to a health
36 care professional for such health care service. An insurer may not
37 retroactively deny, reduce, or recoup payment from a health care profes-
38 sional for such health care service for reasons related to medical
39 necessity or appropriateness of care;
40 (xiv) an insurer may not retroactively deny, reduce, or recoup payment
41 from a health care professional for a health care service for which the
42 health care professional has qualified for an automatic preauthorization
43 approval under subparagraph (i) of this paragraph unless the insurer has
44 proven that the health care professional:
45 (A) knowingly and materially misrepresented the health care service in
46 a request for preauthorization or payment submitted to the insurer with
47 the specific intent to deceive and obtain an unlawful payment from the
48 insurer; or
49 (B) failed to substantially perform the health care service;
50 (xv) an insurer may not retroactively deny, reduce or recoup payment
51 from a health care professional for a health care service for which the
52 health care professional has qualified for an automatic preauthorization
53 approval solely on the basis of the rescission of the health care
54 professional's automatic preauthorization approval. Nothing herein shall
55 limit a health care professional's ability to file a complaint with the
56 department;
S. 10268 4
1 (xvi) the insurer shall make available and submit to the superinten-
2 dent, at the superintendent's request, documentation that describes the
3 insurer's process for:
4 (A) determining the specific health care service or services for which
5 an individual health care professional is granted an automatic preau-
6 thorization approval; and
7 (B) any other activity, policy, decision, or determination related to
8 automatic preauthorization approvals; and
9 (xvii) the superintendent shall promulgate regulations to implement
10 the requirements of this section and establish additional minimum stand-
11 ards as appropriate.
12 § 2. Subdivision 1 of section 4902 of the public health law is amended
13 by adding a new paragraph (m) to read as follows:
14 (m) Establishment of automatic preauthorization approval requirements
15 for health care plans to provide to health care professionals providing
16 certain health care services which shall include that:
17 (i) a health care plan that uses a preauthorization process for health
18 care services shall provide an automatic preauthorization approval to a
19 health care professional for a particular health care service if, as
20 defined under this title including but not limited to health care proce-
21 dures, treatments, services, pharmaceutical products, services or dura-
22 ble medical equipment, in the most recent six-month evaluation period,
23 the health care plan has approved not less than ninety percent of the
24 preauthorization requests submitted by such health care professional for
25 the particular health care service. For the purposes of this require-
26 ment, a preauthorization request submitted during the evaluation period
27 shall be considered and counted as a single request and single approval
28 if the request was approved at any point between the date the request
29 was submitted by the health care professional and the final determi-
30 nation by the health care plan, including any re-review or appeal proc-
31 ess. Each insurer shall complete its initial evaluation and issue its
32 determination to each health care professional in its network no later
33 than one hundred eighty days after the effective date of this paragraph.
34 The automatic preauthorization approval shall become effective two
35 hundred twenty-five days after the effective date of this paragraph;
36 (ii) after the initial evaluation has been completed the health care
37 plan shall annually thereafter evaluate whether a health care profes-
38 sional qualifies for an automatic preauthorization approval under
39 subparagraph (i) of this paragraph for additional health care services.
40 Each year, the evaluation shall review preauthorization determinations
41 made in the first six months of the year. Each health care plan shall
42 issue its determination to each health care professional in its network
43 no later than November fifteenth to be effective January first of the
44 following year;
45 (iii) the health care plan may continue the automatic preauthorization
46 approval under subparagraph (i) of this paragraph without evaluating
47 whether the health care professional qualifies for the automatic preau-
48 thorization approval for a particular evaluation period;
49 (iv) a health care professional shall not be required to request an
50 automatic preauthorization approval to qualify for such approval;
51 (v) a health care professional's automatic preauthorization approval
52 under subparagraph (i) of this paragraph shall remain in effect until
53 the thirtieth calendar day after:
54 (A) the date the health care plan notifies the health care profes-
55 sional of the health care plan's determination to rescind the automatic
56 preauthorization approval pursuant to subparagraph (vii) of this para-
S. 10268 5
1 graph if the health care professional does not appeal such determi-
2 nation; or
3 (B) where the health care professional appeals the determination, the
4 date the health care plan notifies the health care professional that an
5 independent review organization has affirmed the health care plan's
6 determination to rescind the automatic preauthorization approval;
7 (vi) where a health care plan does not finalize a rescission determi-
8 nation as specified in subparagraph (vii) of this paragraph, the health
9 care professional shall be considered to have met the criteria to
10 continue to qualify for the automatic preauthorization approval, which
11 shall remain in effect until the following evaluation period;
12 (vii) a health care plan may rescind an exemption from preauthori-
13 zation requirements under subparagraph (i) of this paragraph only:
14 (A) effective January each year;
15 (B) if the health care plan makes a determination on the basis of a
16 retrospective review as specified in subparagraph (ii) of this paragraph
17 for the most recent evaluation period that less than ninety percent of
18 the claims for the particular health care service met the medical neces-
19 sity criteria that would have been used by the health care plan when
20 conducting preauthorization review for the particular health care
21 service during the relevant evaluation period; and
22 (C) the health care plan complies with all other applicable require-
23 ments of this paragraph and the health care plan notifies the health
24 care professional not less than thirty calendar days before the proposed
25 rescission is to take effect, together with the sample of claims used to
26 make the determination pursuant to clause (B) of this subparagraph and a
27 plain language explanation of the health care professional's right to
28 appeal such determination and instructions on how to initiate such
29 appeal;
30 (viii) notwithstanding any contrary provision of subparagraph (i) of
31 this paragraph, a health care plan may deny an automatic preauthori-
32 zation approval:
33 (A) if the health care professional does not have the approval at the
34 time of the relevant evaluation period; and
35 (B) the health care plan provides the health care professional with
36 actual statistics and data for the relevant preauthorization request
37 evaluation period and detailed information sufficient to demonstrate
38 that the health care professional does not meet the criteria for an
39 automatic preauthorization approval pursuant to subparagraph (i) of this
40 paragraph for the particular health care service;
41 (ix) after a final determination or review affirming the rescission or
42 denial of an automatic preauthorization approval for a specific health
43 care service under this paragraph, a health care professional shall be
44 eligible for consideration of such approval for the same health care
45 service after the evaluation period following the evaluation period
46 which formed the basis of the rescission or denial of such approval;
47 (x) the health care plan shall, not later than five business days
48 after determining that a health care professional qualifies for an auto-
49 matic preauthorization approval pursuant to subparagraph (i) of this
50 paragraph, provide to a health care professional a notice that shall
51 include:
52 (A) a statement that the health care professional qualifies for an
53 automatic preauthorization approval pursuant to this paragraph;
54 (B) a description of the health care services to which such automatic
55 preauthorization approval applies; and
S. 10268 6
1 (C) a statement of the duration that such automatic approval shall
2 remain in effect;
3 (xi) when the health care professional submits a preauthorization
4 request for a health care service for which the health care professional
5 qualifies for an automatic preauthorization approval under subparagraph
6 (i) of this paragraph, the health care plan shall promptly issue an
7 automatic preauthorization approval for such health care service;
8 (xii) nothing in this paragraph shall be construed to:
9 (A) authorize a health care professional to provide a health care
10 service outside the scope of such health care professional's applicable
11 license; or
12 (B) prohibit a health care plan from performing a retrospective review
13 of the health care service pursuant to section forty-nine hundred three
14 of this title;
15 (xiii) when a health care professional provides a health care service
16 covered by the health care professional's automatic preauthorization
17 approval, the service is deemed medically necessary by virtue of the
18 automatic preauthorization approval. For every claim submitted by a
19 health care professional for such service, each health care plan shall
20 promptly pay the full payment to the health care professional. A health
21 care plan is prohibited from denying, withholding, or reducing payment
22 to a health care professional for such health care service. A health
23 care plan may not retroactively deny, reduce, or recoup payment from a
24 health care professional for such health care service for reasons
25 related to medical necessity or appropriateness of care;
26 (xiv) a health care plan may not retroactively deny, reduce, or recoup
27 payment from a health care professional for a health care service for
28 which the health care professional has qualified for an automatic preau-
29 thorization approval under subparagraph (i) of this paragraph unless the
30 health care plan has proven that the health care professional:
31 (A) knowingly and materially misrepresented the health care service in
32 a request for preauthorization or payment submitted to the health care
33 plan with the specific intent to deceive and obtain an unlawful payment
34 from the health care plan; or
35 (B) failed to substantially perform the health care service;
36 (xv) a health care plan may not retroactively deny, reduce or recoup
37 payment from a health care professional for a health care service for
38 which the health care professional has qualified for an automatic preau-
39 thorization approval solely on the basis of the rescission of the health
40 care professional's automatic preauthorization approval. Nothing herein
41 shall limit a health care professional's ability to file a complaint
42 with the department;
43 (xvi) the health care plan shall make available and submit to the
44 commissioner, at the commissioner's request, documentation that
45 describes the health care plan's process for:
46 (A) determining the specific health care service or services for which
47 an individual health care professional is granted an automatic preau-
48 thorization approval; and
49 (B) any other activity, policy, decision, or determination related to
50 automatic preauthorization approvals; and
51 (xvii) the commissioner, in consultation with the superintendent,
52 shall promulgate regulations to implement the requirements of this
53 section and establish additional minimum standards as appropriate.
54 § 3. This act shall take effect on the one hundred eightieth day after
55 it shall have become a law.
