Bill Text: NY A07268 | 2023-2024 | 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 38-8)

Status: (Introduced) 2024-05-22 - reported referred to rules [A07268 Detail]

Download: New_York-2023-A07268-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                         7268--A

                               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,  LAVINE,
          STECK,  TANNOUSIS,  WALLACE,  GUNTHER,  L. ROSENTHAL,  MEEKS,  DAVILA,
          WILLIAMS,  SILLITTI,  ARDILA,  LUNSFORD,  BORES,  PIROZZOLO,   KELLES,
          CARROLL, SIMPSON, BENDETT, REYES, ANGELINO, SAYEGH, THIELE, LEVENBERG,
          SOLAGES,  RAMOS,  DiPIETRO, GALLAHAN, RAGA, HEVESI, CLARK, SHRESTHA --
          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 committee

        AN ACT to amend the public health law and the insurance law, in relation
          to utilization  review  program  standards  and  pre-authorization  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

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD08333-02-4
        A. 7268--A                          2

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

     1  network health care services and the usual and customary cost  for  out-
     2  of-network health care services. An approval of request for pre-authori-
     3  zation  shall  be  valid  for  (1)  the  duration  of  the prescription,
     4  including any authorized refills and (2) the duration of treatment for a
     5  specific condition requested for pre-authorization.
     6    § 5. This act shall take effect on the one hundred eightieth day after
     7  it shall have become a law.