Bill Text: NY A00862 | 2017-2018 | General Assembly | Introduced

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Bill Title: 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.

Spectrum: Moderate Partisan Bill (Democrat 20-4)

Status: (Introduced - Dead) 2018-01-03 - referred to insurance [A00862 Detail]

Download: New_York-2017-A00862-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________
                                           862
                               2017-2018 Regular Sessions
                   IN ASSEMBLY
                                     January 9, 2017
                                       ___________
        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, SEPULVEDA, SIMANOWITZ -- read once and referred to the Commit-
          tee on Insurance
        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 chapter 371 of the laws  of  2015,  is  amended  to  read  as
     3  follows:
     4    (b)  (1)  A  utilization  review agent shall make a utilization review
     5  determination involving health care services which require  pre-authori-
     6  zation and provide notice of a determination to the insured or insured's
     7  designee  and  the  insured's  health  care provider by telephone and in
     8  writing within three [business] days of receipt of the necessary  infor-
     9  mation.  To  the  extent  practicable,  such written notification to the
    10  enrollee's health care provider shall be transmitted electronically,  in
    11  a  manner  and  in  a form agreed upon by the parties.  The notification
    12  shall identify: (i) whether the services are  considered  in-network  or
    13  out-of-network;  (ii)  whether the insured will be held harmless for the
    14  services and not be responsible for any payment, other than any applica-
    15  ble co-payment, co-insurance or deductible;  (iii)  as  applicable,  the
    16  dollar  amount  the  health care plan will pay if the service is out-of-
    17  network; and (iv) as applicable, information explaining how  an  insured
    18  may  determine  the  anticipated  out-of-pocket  cost for out-of-network
    19  health care services in a geographical area or zip code based  upon  the
    20  difference  between what the health care plan will reimburse for out-of-
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD01749-01-7
        A. 862                              2
     1  network health care services and the usual and customary cost  for  out-
     2  of-network health care services.
     3    (2)  With  regard to individual or group contracts authorized pursuant
     4  to article thirty-two, forty-three or forty-seven  of  this  chapter  or
     5  article  forty-four of the public health law, for utilization and review
     6  determinations involving proposed mental  health  and/or  substance  use
     7  disorder  services where the insured or the insured's designee has, in a
     8  format prescribed by the superintendent, certified in the  request  that
     9  the  proposed  services  are for an individual who will be appearing, or
    10  has appeared, before a  court  of  competent  jurisdiction  and  may  be
    11  subject to a court order requiring such services, the utilization review
    12  agent  shall  make  a  determination and provide notice of such determi-
    13  nation to the insured or the  insured's  designee  by  telephone  within
    14  seventy-two  hours  of  receipt  of  the  request. Written notice of the
    15  determination to the insured or insured's designee shall  follow  within
    16  three  business days. Where feasible, such telephonic and written notice
    17  shall also be provided to the court.
    18    § 2. Subdivision 2 of section  4903  of  the  public  health  law,  as
    19  amended  by  chapter  371  of  the  laws  of 2015, is amended to read as
    20  follows:
    21    2. (a) A utilization review agent  shall  make  a  utilization  review
    22  determination  involving health care services which require pre-authori-
    23  zation and  provide  notice  of  a  determination  to  the  enrollee  or
    24  enrollee's designee and the enrollee's health care provider by telephone
    25  and  in writing within three [business] days of receipt of the necessary
    26  information. To the extent practicable, such written notification to the
    27  enrollee's health care provider shall be transmitted electronically,  in
    28  a  manner  and  in  a form agreed upon by the parties.  The notification
    29  shall identify; (i) whether the services are  considered  in-network  or
    30  out-of-network;  (ii) and whether the enrollee will be held harmless for
    31  the services and not be responsible for  any  payment,  other  than  any
    32  applicable  co-payment  or co-insurance; (iii) as applicable, the dollar
    33  amount the health care plan will pay if the service  is  out-of-network;
    34  and  (iv)  as  applicable,  information  explaining  how an enrollee may
    35  determine the anticipated out-of-pocket cost for  out-of-network  health
    36  care  services in a geographical area or zip code based upon the differ-
    37  ence between what the health care plan will reimburse for out-of-network
    38  health care services and the usual and customary cost for out-of-network
    39  health care services.
    40    (b) With regard to individual or group contracts  authorized  pursuant
    41  to  article  forty-four of this chapter, for utilization review determi-
    42  nations involving proposed mental health and/or substance  use  disorder
    43  services  where the enrollee or the enrollee's designee has, in a format
    44  prescribed by the superintendent of financial services, certified in the
    45  request that the proposed services are for an  individual  who  will  be
    46  appearing, or has appeared, before a court of competent jurisdiction and
    47  may be subject to a court order requiring such services, the utilization
    48  review  agent  shall  make  a  determination  and provide notice of such
    49  determination to the enrollee or the enrollee's  designee  by  telephone
    50  within  seventy-two  hours  of receipt of the request. Written notice of
    51  the determination to the enrollee or enrollee's  designee  shall  follow
    52  within  three business days. Where feasible, such telephonic and written
    53  notice shall also be provided to the court.
    54    § 3. This act shall take effect immediately.