Bill Text: NY A07268 | 2023-2024 | General Assembly | Introduced

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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 33-8)

Status: (Introduced) 2024-01-03 - referred to insurance [A07268 Detail]

Download: New_York-2023-A07268-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          7268

                               2023-2024 Regular Sessions

                   IN ASSEMBLY

                                      May 16, 2023
                                       ___________

        Introduced  by  M.  of A. WEPRIN, WOERNER, TAYLOR, SANTABARBARA, COLTON,
          LUPARDO, STIRPE, EPSTEIN, PAULIN, NORRIS,  SEAWRIGHT,  SIMON,  JOYNER,
          LAVINE, STECK, TANNOUSIS, WALLACE, GUNTHER, L. ROSENTHAL, MEEKS, DAVI-
          LA,  WILLIAMS,  SILLITTI -- read once and referred to the Committee on
          Insurance

        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-
    19  sary information if the request is for an enrollee with a medical condi-
    20  tion  that  places the health of the insured in serious jeopardy without
    21  the health care services  recommended  by  the  enrollee's  health  care

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD08333-01-3
        A. 7268                             2

     1  professional,  or  for  inpatient  rehabilitation  services following an
     2  inpatient hospital admission provided by a hospital or  skilled  nursing
     3  facility,  within  one business day of receipt of the necessary informa-
     4  tion.  The  notification shall identify[;]: (i) whether the services are
     5  considered in-network or out-of-network; (ii) and whether  the  enrollee
     6  will  be  held  harmless for the services and not be responsible for any
     7  payment, other than any applicable co-payment or co-insurance; (iii)  as
     8  applicable,  the  dollar  amount  the  health  care plan will pay if the
     9  service is out-of-network; and (iv) as applicable, information  explain-
    10  ing how an enrollee may determine the anticipated out-of-pocket cost for
    11  out-of-network  health  care services in a geographical area or zip code
    12  based upon the difference between what the health care plan  will  reim-
    13  burse  for out-of-network health care services and the usual and custom-
    14  ary cost for out-of-network health care  services.  An  approval  for  a
    15  request for pre-authorization shall be valid for (1) the duration of the
    16  prescription,  including  any authorized refills and (2) the duration of
    17  treatment for a specific condition as requested by the enrollee's health
    18  care provider.
    19    § 3. Paragraph 3 of subsection (a) of section 4902  of  the  insurance
    20  law,  as added by chapter 705 of the laws of 1996, is amended to read as
    21  follows:
    22    (3) Utilization of written clinical review criteria developed pursuant
    23  to a utilization  review  plan.  Such  clinical  review  criteria  shall
    24  utilize  recognized  evidence-based  and  peer  reviewed clinical review
    25  criteria that take into account the needs of  a  typical  patient  popu-
    26  lations and diagnoses;
    27    §  4.  Paragraph  1 of subsection (b) of section 4903 of the insurance
    28  law, as separately amended by section 16 of part YY  and  section  7  of
    29  part  KKK  of  chapter  56  of  the  laws of 2020, is amended to read as
    30  follows:
    31    (1) A utilization review agent shall make a utilization review  deter-
    32  mination  involving health care services which require pre-authorization
    33  and provide notice of a determination to the insured or insured's desig-
    34  nee and the insured's health care provider by telephone and  in  writing
    35  within  [three business days] seventy-two hours of receipt of the neces-
    36  sary information, within  twenty-four  hours  of  receipt  of  necessary
    37  information  if  the  request is for an insured with a medical condition
    38  that places the health of the insured in serious  jeopardy  without  the
    39  health  care services recommended by the insured's health care provider,
    40  or for inpatient rehabilitation services following an inpatient hospital
    41  admission provided by a hospital or skilled nursing facility, within one
    42  business day of receipt of the necessary information.  The  notification
    43  shall  identify:  (i)  whether the services are considered in-network or
    44  out-of-network; (ii) whether the insured will be held harmless  for  the
    45  services and not be responsible for any payment, other than any applica-
    46  ble  co-payment,  co-insurance  or  deductible; (iii) as applicable, the
    47  dollar amount the health care plan will pay if the  service  is  out-of-
    48  network;  and  (iv) as applicable, information explaining how an insured
    49  may determine the  anticipated  out-of-pocket  cost  for  out-of-network
    50  health  care  services in a geographical area or zip code based upon the
    51  difference between what the health care plan will reimburse for  out-of-
    52  network  health  care services and the usual and customary cost for out-
    53  of-network health care services. An approval of request for pre-authori-
    54  zation shall  be  valid  for  (1)  the  duration  of  the  prescription,
    55  including any authorized refills and (2) the duration of treatment for a
    56  specific condition requested for pre-authorization.
        A. 7268                             3

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