Bill Text: NY A07129 | 2021-2022 | General Assembly | Amended

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Bill Title: Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; relates to prescription drug formulary changes and pre-authorization for certain health care services.

Spectrum: Moderate Partisan Bill (Democrat 28-5)

Status: (Introduced - Dead) 2022-01-21 - print number 7129a [A07129 Detail]

Download: New_York-2021-A07129-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                         7129--A

                               2021-2022 Regular Sessions

                   IN ASSEMBLY

                                     April 23, 2021
                                       ___________

        Introduced  by M. of A. GOTTFRIED, WOERNER, TAYLOR, SANTABARBARA, SOLAG-
          ES, COLTON, LUPARDO, MONTESANO, ENGLEBRIGHT, STIRPE, EPSTEIN,  THIELE,
          PAULIN,  WALCZYK, NORRIS, SEAWRIGHT, SIMON, ABINANTI, JOYNER, M. MILL-
          ER, LAVINE, STECK, TANNOUSIS -- read once and referred to the  Commit-
          tee  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 public health law and the insurance law, in relation
          to utilization review program standards, and in  relation  to  pre-au-
          thorization of health care services

          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:

     1    Section 1.  Paragraph (c) of subdivision 1  of  section  4902  of  the
     2  public  health  law,  as  added  by  chapter 705 of the laws of 1996, is
     3  amended to read as follows:
     4    (c) Utilization of written clinical review criteria developed pursuant
     5  to a utilization  review  plan.  Such  clinical  review  criteria  shall
     6  utilize  recognized  evidence-based  and  peer  reviewed clinical review
     7  criteria that take into account the needs of  a  typical  patient  popu-
     8  lations and diagnoses;
     9    §  2.  Paragraph  (a)  of  subdivision 2 of section 4903 of the public
    10  health law, as separately amended by section 13 of part YY and section 3
    11  of part KKK of chapter 56 of the laws of 2020, is  amended  to  read  as
    12  follows:
    13    (a)  A utilization review agent shall make a utilization review deter-
    14  mination involving health care services which require  pre-authorization
    15  and  provide  notice  of  a  determination to the enrollee or enrollee's
    16  designee and the enrollee's health care provider  by  telephone  and  in
    17  writing within [three business days] seventy-two hours of receipt of the
    18  necessary information, within twenty-four hours of the receipt of neces-

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03897-05-2
        A. 7129--A                          2

     1  sary information if the request is for an enrollee with a medical condi-
     2  tion  that  places the health of the insured in serious jeopardy without
     3  the health care services  recommended  by  the  enrollee's  health  care
     4  professional,  or  for  inpatient  rehabilitation  services following an
     5  inpatient hospital admission provided by a hospital or  skilled  nursing
     6  facility,  within  one business day of receipt of the necessary informa-
     7  tion. The notification shall identify[;]: (i) whether the  services  are
     8  considered  in-network  or out-of-network; (ii) and whether the enrollee
     9  will be held harmless for the services and not be  responsible  for  any
    10  payment,  other than any applicable co-payment or co-insurance; (iii) as
    11  applicable, the dollar amount the health  care  plan  will  pay  if  the
    12  service  is out-of-network; and (iv) as applicable, information explain-
    13  ing how an enrollee may determine the anticipated out-of-pocket cost for
    14  out-of-network health care services in a geographical area or  zip  code
    15  based  upon  the difference between what the health care plan will reim-
    16  burse for out-of-network health care services and the usual and  custom-
    17  ary  cost  for  out-of-network  health  care services. An approval for a
    18  request for pre-authorization shall be valid for (1) the duration of the
    19  prescription, including any authorized refills and (2) the  duration  of
    20  treatment for a specific condition as requested by the enrollee's health
    21  care provider.
    22    §  3.  Paragraph  3 of subsection (a) of section 4902 of the insurance
    23  law, as added by chapter 705 of the laws of 1996, is amended to read  as
    24  follows:
    25    (3) Utilization of written clinical review criteria developed pursuant
    26  to  a  utilization  review  plan.  Such  clinical  review criteria shall
    27  utilize recognized evidence-based  and  peer  reviewed  clinical  review
    28  criteria  that  take  into  account the needs of a typical patient popu-
    29  lations and diagnoses;
    30    § 4. Paragraph 1 of subsection (b) of section 4903  of  the  insurance
    31  law,  as  separately  amended  by section 16 of part YY and section 7 of
    32  part KKK of chapter 56 of the laws  of  2020,  is  amended  to  read  as
    33  follows:
    34    (1)  A utilization review agent shall make a utilization review deter-
    35  mination involving health care services which require  pre-authorization
    36  and provide notice of a determination to the insured or insured's desig-
    37  nee  and  the insured's health care provider by telephone and in writing
    38  within [three business days] seventy-two hours of receipt of the  neces-
    39  sary  information,  within  twenty-four  hours  of  receipt of necessary
    40  information if the request is for an insured with  a  medical  condition
    41  that  places  the  health of the insured in serious jeopardy without the
    42  health care services recommended by the insured's health care  provider,
    43  or for inpatient rehabilitation services following an inpatient hospital
    44  admission provided by a hospital or skilled nursing facility, within one
    45  business  day of receipt of the necessary information.  The notification
    46  shall identify: (i) whether the services are  considered  in-network  or
    47  out-of-network;  (ii)  whether the insured will be held harmless for the
    48  services and not be responsible for any payment, other than any applica-
    49  ble co-payment, co-insurance or deductible;  (iii)  as  applicable,  the
    50  dollar  amount  the  health care plan will pay if the service is out-of-
    51  network; and (iv) as applicable, information explaining how  an  insured
    52  may  determine  the  anticipated  out-of-pocket  cost for out-of-network
    53  health care services in a geographical area or zip code based  upon  the
    54  difference  between what the health care plan will reimburse for out-of-
    55  network health care services and the usual and customary cost  for  out-
    56  of-network health care services. An approval of request for pre-authori-
        A. 7129--A                          3

     1  zation  shall  be  valid  for  (1)  the  duration  of  the prescription,
     2  including any authorized refills and (2) the duration of treatment for a
     3  specific condition requested for pre-authorization.
     4    §  5. Subsection (a) of section 3238 of the insurance law, as added by
     5  chapter 451 of the laws of 2007, is amended to read as follows:
     6    (a) An insurer, corporation organized pursuant to article  forty-three
     7  of  this  chapter,  municipal cooperative health benefits plan certified
     8  pursuant to article forty-seven of this chapter, or  health  maintenance
     9  organization  and  other  organizations  certified  pursuant  to article
    10  forty-four of the public health law ("health plan") shall pay claims for
    11  a health care service for which a pre-authorization was required by, and
    12  received from, the health plan prior to the  rendering  of  such  health
    13  care  service,  and  eligibility  confirmed  on  the day of the service,
    14  unless:
    15    (1) [(i) the insured, subscriber, or enrollee was not a covered person
    16  at the time the health care service was rendered.
    17    (ii) Notwithstanding the provisions of subparagraph (i) of this  para-
    18  graph,  a  health  plan  shall  not  deny  a  claim on this basis if the
    19  insured's, subscriber's or enrollee's coverage was retroactively  termi-
    20  nated  more  than  one  hundred twenty days after the date of the health
    21  care service, provided that the claim is submitted  within  ninety  days
    22  after  the  date  of  the health care service. If the claim is submitted
    23  more than ninety days after the date of the  health  care  service,  the
    24  health  plan  shall have thirty days after the claim is received to deny
    25  the claim on the basis that the insured, subscriber or enrollee was  not
    26  a covered person on the date of the health care service.
    27    (2)] the submission of the claim with respect to an insured, subscrib-
    28  er or enrollee was not timely under the terms of the applicable provider
    29  contract,  if  the  claim  is  submitted by a provider, or the policy or
    30  contract, if the claim is submitted by the insured, subscriber or enrol-
    31  lee;
    32    [(3)] (2) at the time the pre-authorization was issued,  the  insured,
    33  subscriber  or  enrollee  had  not  exhausted contract or policy benefit
    34  limitations based on information available to the health  plan  at  such
    35  time,  but subsequently exhausted contract or policy benefit limitations
    36  after authorization was issued; provided, however, that the health  plan
    37  shall  include  in  the  notice  of  determination  required pursuant to
    38  subsection (b) of section four thousand nine hundred three of this chap-
    39  ter and subdivision two of  section  forty-nine  hundred  three  of  the
    40  public  health law that the visits authorized might exceed the limits of
    41  the contract or policy and accordingly would not be  covered  under  the
    42  contract or policy;
    43    [(4)]  (3) the pre-authorization was based on materially inaccurate or
    44  incomplete information provided by the insured, subscriber or  enrollee,
    45  the  designee of the insured, subscriber or enrollee, or the health care
    46  provider such that if the  correct  or  complete  information  had  been
    47  provided, such pre-authorization would not have been granted; or
    48    [(5)  the  pre-authorized service was related to a pre-existing condi-
    49  tion that was excluded from coverage; or
    50    (6)] (4) there is a reasonable basis supported by specific information
    51  available for review by the superintendent that the insured,  subscriber
    52  or enrollee, the designee of the insured, subscriber or enrollee, or the
    53  health care provider has engaged in fraud or abuse.
    54    §  6.  This  act shall take effect on the ninetieth day after it shall
    55  have become a law.