A05129 Summary:
| BILL NO | A05129A |
| SAME AS | SAME AS S01397-A |
| SPONSOR | Braunstein |
| COSPNSR | Weprin, Gottfried, Otis, Bronson, Skoufis, Galef, Gunther, Crespo, O'Donnell, Goodell, Montesano, Zebrowski, McDonough, Hooper, Steck, Abinanti, Friend |
| MLTSPNSR | Cook, Kearns, Peoples-Stokes, Perry, Ramos, Rivera, Schimel, Sepulveda, Simanowitz |
| Amd §4903, Ins L; amd §4903, Pub Health L | |
| Shortens time frames during which an insurer has to determine whether a pre-authorization request is medically necessary from three business days to three days. | |
A05129 Actions:
| BILL NO | A05129A | |||||||||||||||||||||||||||||||||||||||||||||||||
| 02/12/2015 | referred to insurance | |||||||||||||||||||||||||||||||||||||||||||||||||
| 01/06/2016 | referred to insurance | |||||||||||||||||||||||||||||||||||||||||||||||||
| 02/02/2016 | amend and recommit to insurance | |||||||||||||||||||||||||||||||||||||||||||||||||
| 02/02/2016 | print number 5129a | |||||||||||||||||||||||||||||||||||||||||||||||||
A05129 Committee Votes:
Go to topA05129 Floor Votes:
There are no votes for this bill in this legislative session.
Go to topA05129 Text:
Go to topSTATE OF NEW YORK ________________________________________________________________________ 5129--A 2015-2016 Regular Sessions IN ASSEMBLY February 12, 2015 ___________ Introduced by M. of A. BRAUNSTEIN, WEPRIN, GOTTFRIED, OTIS, BRONSON, SKOUFIS, GALEF, GUNTHER, CRESPO, O'DONNELL, GOODELL, MONTESANO, ZEBROWSKI, McDONOUGH, HOOPER, STECK, ABINANTI, FRIEND -- Multi-Spon- sored by -- M. of A. COOK, KEARNS, PEOPLES-STOKES, PERRY, RAMOS, RIVERA, SCHIMEL, SEPULVEDA, SIMANOWITZ -- read once and referred to the Committee on Insurance -- recommitted to the Committee on Insur- ance in accordance with Assembly Rule 3, sec. 2 -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee AN ACT to amend the insurance law and the public health law, in relation to shortening time frames during which an insurer has to determine whether a pre-authorization request is medically necessary The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (b) of section 4903 of the insurance law, as 2 amended by section 12 of part H of chapter 60 of the laws of 2014, is 3 amended to read as follows: 4 (b) A utilization review agent shall make a utilization review deter- 5 mination involving health care services which require pre-authorization 6 and provide notice of a determination to the insured or insured's desig- 7 nee and the insured's health care provider by telephone and in writing 8 within three [business] days of receipt of the necessary information. To 9 the extent practicable, such written notification to the enrollee's 10 health care provider shall be transmitted electronically, in a manner 11 and in a form agreed upon by the parties. The notification shall iden- 12 tify: (1) whether the services are considered in-network or out-of-net- 13 work; (2) whether the insured will be held harmless for the services and 14 not be responsible for any payment, other than any applicable co-pay- 15 ment, co-insurance or deductible; (3) as applicable, the dollar amount 16 the health care plan will pay if the service is out-of-network; and (4) 17 as applicable, information explaining how an insured may determine the EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD03427-04-6A. 5129--A 2 1 anticipated out-of-pocket cost for out-of-network health care services 2 in a geographical area or zip code based upon the difference between 3 what the health care plan will reimburse for out-of-network health care 4 services and the usual and customary cost for out-of-network health care 5 services. 6 § 1-a. Subsection (b) of section 4903 of the insurance law, as amended 7 by chapter 371 of the laws of 2015, is amended to read as follows: 8 (b) (1) A utilization review agent shall make a utilization review 9 determination involving health care services which require pre-authori- 10 zation and provide notice of a determination to the insured or insured's 11 designee and the insured's health care provider by telephone and in 12 writing within three [business] days of receipt of the necessary infor- 13 mation. To the extent practicable, such written notification to the 14 enrollee's health care provider shall be transmitted electronically, in 15 a manner and in a form agreed upon by the parties. The notification 16 shall identify: (i) whether the services are considered in-network or 17 out-of-network; (ii) whether the insured will be held harmless for the 18 services and not be responsible for any payment, other than any applica- 19 ble co-payment, co-insurance or deductible; (iii) as applicable, the 20 dollar amount the health care plan will pay if the service is out-of- 21 network; and (iv) as applicable, information explaining how an insured 22 may determine the anticipated out-of-pocket cost for out-of-network 23 health care services in a geographical area or zip code based upon the 24 difference between what the health care plan will reimburse for out-of- 25 network health care services and the usual and customary cost for out- 26 of-network health care services. 27 (2) With regard to individual or group contracts authorized pursuant 28 to article thirty-two, forty-three or forty-seven of this chapter or 29 article forty-four of the public health law, for utilization and review 30 determinations involving proposed mental health and/or substance use 31 disorder services where the insured or the insured's designee has, in a 32 format prescribed by the superintendent, certified in the request that 33 the proposed services are for an individual who will be appearing, or 34 has appeared, before a court of competent jurisdiction and may be 35 subject to a court order requiring such services, the utilization review 36 agent shall make a determination and provide notice of such determi- 37 nation to the insured or the insured's designee by telephone within 38 seventy-two hours of receipt of the request. Written notice of the 39 determination to the insured or insured's designee shall follow within 40 three business days. Where feasible, such telephonic and written notice 41 shall also be provided to the court. 42 § 2. Subdivision 2 of section 4903 of the public health law, as 43 amended by section 22 of part H of chapter 60 of the laws of 2014, is 44 amended to read as follows: 45 2. A utilization review agent shall make a utilization review determi- 46 nation involving health care services which require pre-authorization 47 and provide notice of a determination to the enrollee or enrollee's 48 designee and the enrollee's health care provider by telephone and in 49 writing within three [business] days of receipt of the necessary infor- 50 mation. To the extent practicable, such written notification to the 51 enrollee's health care provider shall be transmitted electronically, in 52 a manner and in a form agreed upon by the parties. The notification 53 shall identify; (a) whether the services are considered in-network or 54 out-of-network; (b) and whether the enrollee will be held harmless for 55 the services and not be responsible for any payment, other than any 56 applicable co-payment or co-insurance; (c) as applicable, the dollarA. 5129--A 3 1 amount the health care plan will pay if the service is out-of-network; 2 and (d) as applicable, information explaining how an enrollee may deter- 3 mine the anticipated out-of-pocket cost for out-of-network health care 4 services in a geographical area or zip code based upon the difference 5 between what the health care plan will reimburse for out-of-network 6 health care services and the usual and customary cost for out-of-network 7 health care services. 8 § 2-a. Subdivision 2 of section 4903 of the public health law, as 9 amended by chapter 371 of the laws of 2015, is amended to read as 10 follows: 11 2. (a) A utilization review agent shall make a utilization review 12 determination involving health care services which require pre-authori- 13 zation and provide notice of a determination to the enrollee or 14 enrollee's designee and the enrollee's health care provider by telephone 15 and in writing within three [business] days of receipt of the necessary 16 information. To the extent practicable, such written notification to the 17 enrollee's health care provider shall be transmitted electronically, in 18 a manner and in a form agreed upon by the parties. The notification 19 shall identify; (i) whether the services are considered in-network or 20 out-of-network; (ii) and whether the enrollee will be held harmless for 21 the services and not be responsible for any payment, other than any 22 applicable co-payment or co-insurance; (iii) as applicable, the dollar 23 amount the health care plan will pay if the service is out-of-network; 24 and (iv) as applicable, information explaining how an enrollee may 25 determine the anticipated out-of-pocket cost for out-of-network health 26 care services in a geographical area or zip code based upon the differ- 27 ence between what the health care plan will reimburse for out-of-network 28 health care services and the usual and customary cost for out-of-network 29 health care services. 30 (b) With regard to individual or group contracts authorized pursuant 31 to article forty-four of this chapter, for utilization review determi- 32 nations involving proposed mental health and/or substance use disorder 33 services where the enrollee or the enrollee's designee has, in a format 34 prescribed by the superintendent of financial services, certified in the 35 request that the proposed services are for an individual who will be 36 appearing, or has appeared, before a court of competent jurisdiction and 37 may be subject to a court order requiring such services, the utilization 38 review agent shall make a determination and provide notice of such 39 determination to the enrollee or the enrollee's designee by telephone 40 within seventy-two hours of receipt of the request. Written notice of 41 the determination to the enrollee or enrollee's designee shall follow 42 within three business days. Where feasible, such telephonic and written 43 notice shall also be provided to the court. 44 § 3. This act shall take effect immediately, provided, however, that 45 sections one-a and two-a of this act shall take effect on the same date 46 and in the same manner as chapter 371 of the laws of 2015, takes effect.