Bill Text: NY A00859 | 2023-2024 | General Assembly | Amended
Bill Title: Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstances.
Spectrum: Moderate Partisan Bill (Democrat 14-2)
Status: (Introduced) 2024-01-22 - print number 859a [A00859 Detail]
Download: New_York-2023-A00859-Amended.html
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. LBD02507-06-4A. 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; orA. 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; andA. 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.
