A00859 Summary:

BILL NOA00859A
 
SAME ASSAME AS S02680-A
 
SPONSORMcDonald
 
COSPNSRWoerner, Steck, Seawright, Sillitti, Gunther, Stirpe, Cunningham, Rivera, Kelles, Alvarez, Lupardo, Lemondes, Bendett, Shrestha
 
MLTSPNSRSimon
 
Amd §4902, Ins L; amd §4902, Pub Health L
 
Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstances.
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A00859 Actions:

BILL NOA00859A
 
01/11/2023referred to insurance
01/03/2024referred to insurance
01/22/2024amend (t) and recommit to insurance
01/22/2024print number 859a
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A00859 Committee Votes:

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A00859 Floor Votes:

There are no votes for this bill in this legislative session.
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A00859 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         859--A
 
                               2023-2024 Regular Sessions
 
                   IN ASSEMBLY
 
                                    January 11, 2023
                                       ___________
 
        Introduced  by  M.  of A. McDONALD, WOERNER, STECK, SEAWRIGHT, SILLITTI,
          GUNTHER, STIRPE,  CUNNINGHAM,  RIVERA,  KELLES,  ALVAREZ,  LUPARDO  --
          Multi-Sponsored by -- M.  of A. SIMON -- read once and referred to the
          Committee 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 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 15 to read as follows:
     3    (15) 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-
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02507-06-4

        A. 859--A                           2
 
     1  nation  by  the insurer, including any re-review or appeal process. Each
     2  insurer shall complete its initial evaluation  and  issue  its  determi-
     3  nation to each health care professional in its network no later than one
     4  hundred  eighty  days  after  the  effective date of this paragraph. The
     5  automatic preauthorization approval shall become effective  two  hundred
     6  twenty-five days after the effective date of this paragraph;
     7    (ii) after the initial evaluation has been completed the insurer shall
     8  annually  thereafter  evaluate whether a health care professional quali-
     9  fies for an automatic preauthorization approval under  subparagraph  (i)
    10  of  this  paragraph  for additional health care services. Each year, the
    11  evaluation shall review  preauthorization  determinations  made  in  the
    12  first six months of the year. Each insurer shall issue its determination
    13  to  each  health care professional in its network no later than November
    14  fifteenth to be effective January first of the following year;
    15    (iii) the insurer may continue the automatic preauthorization approval
    16  under subparagraph (i) of this paragraph without evaluating whether  the
    17  health   care  professional  qualifies  for  automatic  preauthorization
    18  approval for a particular evaluation period;
    19    (iv) a health care professional shall not be required  to  request  an
    20  automatic preauthorization approval to qualify for such approval;
    21    (v)  a  health care professional's automatic preauthorization approval
    22  under subparagraph (i) of this paragraph shall remain  in  effect  until
    23  the thirtieth calendar day after:
    24    (A)  the date the insurer notifies the health care professional of the
    25  insurer's  determination  to  rescind  the  automatic   preauthorization
    26  approval  pursuant to subparagraph (vii) of this paragraph if the health
    27  care professional does not appeal such determination; or
    28    (B) where the health care professional appeals the determination,  the
    29  date the insurer notifies the health care professional that an independ-
    30  ent  review  organization  has  affirmed  the insurer's determination to
    31  rescind the automatic preauthorization approval;
    32    (vi) where an insurer does not finalize a rescission determination  as
    33  specified  in  subparagraph  (vii)  of  this  paragraph, the health care
    34  professional shall be considered to have met the criteria to continue to
    35  qualify for the automatic preauthorization approval, which shall  remain
    36  in effect until the following evaluation period;
    37    (vii)  an  insurer  may rescind an automatic preauthorization approval
    38  under subparagraph (i) of this paragraph only:
    39    (A) effective January of each year;
    40    (B) if the insurer makes a determination on the basis of a  retrospec-
    41  tive  review as specified in subparagraph (ii) of this paragraph for the
    42  most recent evaluation period that  less  than  ninety  percent  of  the
    43  claims  for the particular health care service met the medical necessity
    44  criteria that would have been used by the insurer when conducting preau-
    45  thorization review for the particular health  care  service  during  the
    46  relevant evaluation period; and
    47    (C)  the  insurer  complies  with all other applicable requirements of
    48  this paragraph and the insurer notifies the health care professional not
    49  less than thirty calendar days before the proposed rescission is to take
    50  effect, together with the sample of claims used  to  make  the  determi-
    51  nation  pursuant to clause (B) of this subparagraph and a plain language
    52  explanation of the health  care  professional's  right  to  appeal  such
    53  determination and instructions on how to initiate such appeal;
    54    (viii)  notwithstanding  any contrary provision of subparagraph (i) of
    55  this paragraph,  an  insurer  may  deny  an  automatic  preauthorization
    56  approval:

        A. 859--A                           3
 
     1    (A)  if the health care professional does not have the approval at the
     2  time of the relevant evaluation period; and
     3    (B)  the  insurer  provides  the  health care professional with actual
     4  statistics and data for the relevant preauthorization request evaluation
     5  period and detailed  information  sufficient  to  demonstrate  that  the
     6  health  care  professional  does  not meet the criteria for an automatic
     7  preauthorization approval pursuant to subparagraph (i) of this paragraph
     8  for the particular health care service;
     9    (ix) after a final determination or review affirming the rescission or
    10  denial of an automatic preauthorization approval for a  specific  health
    11  care  service  under this paragraph, a health care professional shall be
    12  eligible for consideration of such approval for  the  same  health  care
    13  service  after  the  evaluation  period  following the evaluation period
    14  which formed the basis of the rescission or denial of such approval;
    15    (x) the insurer shall, not later than five business days after  deter-
    16  mining that a health care professional qualifies for an automatic preau-
    17  thorization  approval  pursuant  to  subparagraph (i) of this paragraph,
    18  provide to a health care professional a notice that shall include:
    19    (A) a statement that the health care  professional  qualifies  for  an
    20  automatic preauthorization approval pursuant to this paragraph;
    21    (B)  a description of the health care services to which such automatic
    22  preauthorization applies; and
    23    (C) a statement of the duration that  such  automatic  approval  shall
    24  remain in effect;
    25    (xi)  when  the  health  care  professional submits a preauthorization
    26  request for a health care service for which the health care professional
    27  qualifies for an automatic preauthorization approval under  subparagraph
    28  (i)  of  this  paragraph,  the insurer shall promptly issue an automatic
    29  preauthorization approval for such health care service;
    30    (xii) nothing in this paragraph may be construed to:
    31    (A) authorize a health care professional  to  provide  a  health  care
    32  service  outside the scope of such health care professional's applicable
    33  license; or
    34    (B) prohibit a health insurer from performing a  retrospective  review
    35  of  the health care service pursuant to section forty-nine hundred three
    36  of this title;
    37    (xiii) when a health care professional provides a health care  service
    38  covered  by  the  health  care professional's automatic preauthorization
    39  approval, the service is deemed medically necessary  by  virtue  of  the
    40  automatic  preauthorization  approval.  For  every  claim submitted by a
    41  health care professional for such service, each insurer  shall  promptly
    42  pay  the  full  payment  to  the health care professional. An insurer is
    43  prohibited from denying, withholding, or reducing payment  to  a  health
    44  care  professional  for  such  health  care  service. An insurer may not
    45  retroactively deny, reduce, or recoup payment from a health care profes-
    46  sional for such health care  service  for  reasons  related  to  medical
    47  necessity or appropriateness of care;
    48    (xiv) an insurer may not retroactively deny, reduce, or recoup payment
    49  from  a health care professional for a health care service for which the
    50  health care professional has qualified for an automatic preauthorization
    51  approval under subparagraph (i) of this paragraph unless the insurer has
    52  proven that the health care professional:
    53    (A) knowingly and materially misrepresented the health care service in
    54  a request for preauthorization or payment submitted to the insurer  with
    55  the  specific  intent to deceive and obtain an unlawful payment from the
    56  insurer; or

        A. 859--A                           4
 
     1    (B) failed to substantially perform the health care service;
     2    (xv)  an  insurer may not retroactively deny, reduce or recoup payment
     3  from a health care professional for a health care service for which  the
     4  health care professional has qualified for an automatic preauthorization
     5  approval  solely  on  the  basis  of  the  rescission of the health care
     6  professional's automatic preauthorization approval. Nothing herein shall
     7  limit a health care professional's ability to file a complaint with  the
     8  department;
     9    (xvi)  the  insurer shall make available and submit to the superinten-
    10  dent, at the superintendent's request, documentation that describes  the
    11  insurer's process for:
    12    (A) determining the specific health care service or services for which
    13  an  individual  health  care professional is granted an automatic preau-
    14  thorization approval; and
    15    (B) any other activity, policy, decision, or determination related  to
    16  automatic preauthorization approvals; and
    17    (xvii)  the  superintendent  shall promulgate regulations to implement
    18  the requirements of this section and establish additional minimum stand-
    19  ards as appropriate.
    20    § 2. Subdivision 1 of section 4902 of the public health law is amended
    21  by adding a new paragraph (m) to read as follows:
    22    (m) Establishment of automatic preauthorization approval  requirements
    23  for  health care plans to provide to health care professionals providing
    24  certain health care services which shall include that:
    25    (i) a health care plan that uses a preauthorization process for health
    26  care services shall provide an automatic preauthorization approval to  a
    27  health  care  professional  for  a particular health care service if, as
    28  defined under this title including but not limited to health care proce-
    29  dures, treatments, services, pharmaceutical products, services or  dura-
    30  ble  medical  equipment, in the most recent six-month evaluation period,
    31  the health care plan has approved not less than ninety  percent  of  the
    32  preauthorization requests submitted by such health care professional for
    33  the  particular  health  care service. For the purposes of this require-
    34  ment, a preauthorization request submitted during the evaluation  period
    35  shall  be considered and counted as a single request and single approval
    36  if the request was approved at any point between the  date  the  request
    37  was  submitted  by  the  health care professional and the final determi-
    38  nation by the health care plan, including any re-review or appeal  proc-
    39  ess.  Each  insurer  shall complete its initial evaluation and issue its
    40  determination to each health care professional in its network  no  later
    41  than one hundred eighty days after the effective date of this paragraph.
    42  The  automatic  preauthorization  approval  shall  become  effective two
    43  hundred twenty-five days after the effective date of this paragraph;
    44    (ii) after the initial evaluation has been completed the  health  care
    45  plan  shall  annually  thereafter evaluate whether a health care profes-
    46  sional  qualifies  for  an  automatic  preauthorization  approval  under
    47  subparagraph  (i) of this paragraph for additional health care services.
    48  Each year, the evaluation shall review  preauthorization  determinations
    49  made  in  the  first six months of the year. Each health care plan shall
    50  issue its determination to each health care professional in its  network
    51  no  later  than  November fifteenth to be effective January first of the
    52  following year;
    53    (iii) the health care plan may continue the automatic preauthorization
    54  approval under subparagraph (i) of  this  paragraph  without  evaluating
    55  whether  the health care professional qualifies for the automatic preau-
    56  thorization approval for a particular evaluation period;

        A. 859--A                           5
 
     1    (iv) a health care professional shall not be required  to  request  an
     2  automatic preauthorization approval to qualify for such approval;
     3    (v)  a  health care professional's automatic preauthorization approval
     4  under subparagraph (i) of this paragraph shall remain  in  effect  until
     5  the thirtieth calendar day after:
     6    (A)  the  date  the  health care plan notifies the health care profes-
     7  sional of the health care plan's determination to rescind the  automatic
     8  preauthorization  approval  pursuant to subparagraph (vii) of this para-
     9  graph if the health care professional  does  not  appeal  such  determi-
    10  nation; or
    11    (B)  where the health care professional appeals the determination, the
    12  date the health care plan notifies the health care professional that  an
    13  independent  review  organization  has  affirmed  the health care plan's
    14  determination to rescind the automatic preauthorization approval;
    15    (vi) where a health care plan does not finalize a rescission  determi-
    16  nation  as specified in subparagraph (vii) of this paragraph, the health
    17  care professional shall be  considered  to  have  met  the  criteria  to
    18  continue  to  qualify for the automatic preauthorization approval, which
    19  shall remain in effect until the following evaluation period;
    20    (vii) a health care plan may rescind  an  exemption  from  preauthori-
    21  zation requirements under subparagraph (i) of this paragraph only:
    22    (A) effective January each year;
    23    (B)  if  the  health care plan makes a determination on the basis of a
    24  retrospective review as specified in subparagraph (ii) of this paragraph
    25  for the most recent evaluation period that less than ninety  percent  of
    26  the claims for the particular health care service met the medical neces-
    27  sity  criteria  that  would  have been used by the health care plan when
    28  conducting  preauthorization  review  for  the  particular  health  care
    29  service during the relevant evaluation period; and
    30    (C)  the  health care plan complies with all other applicable require-
    31  ments of this paragraph and the health care  plan  notifies  the  health
    32  care professional not less than thirty calendar days before the proposed
    33  rescission is to take effect, together with the sample of claims used to
    34  make the determination pursuant to clause (B) of this subparagraph and a
    35  plain  language  explanation  of the health care professional's right to
    36  appeal such determination and  instructions  on  how  to  initiate  such
    37  appeal;
    38    (viii)  notwithstanding  any contrary provision of subparagraph (i) of
    39  this paragraph, a health care plan may  deny  an  automatic  preauthori-
    40  zation approval:
    41    (A)  if the health care professional does not have the approval at the
    42  time of the relevant evaluation period; and
    43    (B) the health care plan provides the health  care  professional  with
    44  actual  statistics  and  data  for the relevant preauthorization request
    45  evaluation period and detailed  information  sufficient  to  demonstrate
    46  that  the  health  care  professional  does not meet the criteria for an
    47  automatic preauthorization approval pursuant to subparagraph (i) of this
    48  paragraph for the particular health care service;
    49    (ix) after a final determination or review affirming the rescission or
    50  denial of an automatic preauthorization approval for a  specific  health
    51  care  service  under this paragraph, a health care professional shall be
    52  eligible for consideration of such approval for  the  same  health  care
    53  service  after  the  evaluation  period  following the evaluation period
    54  which formed the basis of the rescission or denial of such approval;
    55    (x) the health care plan shall, not  later  than  five  business  days
    56  after determining that a health care professional qualifies for an auto-

        A. 859--A                           6
 
     1  matic  preauthorization  approval  pursuant  to subparagraph (i) of this
     2  paragraph, provide to a health care professional  a  notice  that  shall
     3  include:
     4    (A)  a  statement  that  the health care professional qualifies for an
     5  automatic preauthorization approval pursuant to this paragraph;
     6    (B) a description of the health care services to which such  automatic
     7  preauthorization approval applies; and
     8    (C)  a  statement  of  the duration that such automatic approval shall
     9  remain in effect;
    10    (xi) when the health  care  professional  submits  a  preauthorization
    11  request for a health care service for which the health care professional
    12  qualifies  for an automatic preauthorization approval under subparagraph
    13  (i) of this paragraph, the health care  plan  shall  promptly  issue  an
    14  automatic preauthorization approval for such health care service;
    15    (xii) nothing in this paragraph shall be construed to:
    16    (A)  authorize  a  health  care  professional to provide a health care
    17  service outside the scope of such health care professional's  applicable
    18  license; or
    19    (B) prohibit a health care plan from performing a retrospective review
    20  of  the health care service pursuant to section forty-nine hundred three
    21  of this title;
    22    (xiii) when a health care professional provides a health care  service
    23  covered  by  the  health  care professional's automatic preauthorization
    24  approval, the service is deemed medically necessary  by  virtue  of  the
    25  automatic  preauthorization  approval.  For  every  claim submitted by a
    26  health care professional for such service, each health care  plan  shall
    27  promptly  pay the full payment to the health care professional. A health
    28  care plan is prohibited from denying, withholding, or  reducing  payment
    29  to  a  health  care  professional for such health care service. A health
    30  care plan may not retroactively deny, reduce, or recoup payment  from  a
    31  health  care  professional  for  such  health  care  service for reasons
    32  related to medical necessity or appropriateness of care;
    33    (xiv) a health care plan may not retroactively deny, reduce, or recoup
    34  payment from a health care professional for a health  care  service  for
    35  which the health care professional has qualified for an automatic preau-
    36  thorization approval under subparagraph (i) of this paragraph unless the
    37  health care plan has proven that the health care professional:
    38    (A) knowingly and materially misrepresented the health care service in
    39  a  request  for preauthorization or payment submitted to the health care
    40  plan with the specific intent to deceive and obtain an unlawful  payment
    41  from the health care plan; or
    42    (B) failed to substantially perform the health care service;
    43    (xv)  a  health care plan may not retroactively deny, reduce or recoup
    44  payment from a health care professional for a health  care  service  for
    45  which the health care professional has qualified for an automatic preau-
    46  thorization approval solely on the basis of the rescission of the health
    47  care professional's automatic preauthorization approval.  Nothing herein
    48  shall  limit  a  health  care professional's ability to file a complaint
    49  with the department;
    50    (xvi) the health care plan shall make  available  and  submit  to  the
    51  commissioner,   at   the   commissioner's  request,  documentation  that
    52  describes the health care plan's process for:
    53    (A) determining the specific health care service or services for which
    54  an individual health care professional is granted  an  automatic  preau-
    55  thorization approval; and

        A. 859--A                           7
 
     1    (B)  any other activity, policy, decision, or determination related to
     2  automatic preauthorization approvals; and
     3    (xvii)  the  commissioner,  in  consultation  with the superintendent,
     4  shall promulgate regulations  to  implement  the  requirements  of  this
     5  section and establish additional minimum standards as appropriate.
     6    § 3. This act shall take effect on the one hundred eightieth day after
     7  it shall have become a law.
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