Bill Text: NY A09908 | 2021-2022 | General Assembly | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Exempts health care professionals from preauthorization requirements where the insurer or health care plan has approved not less than ninety percent of such professional's preauthorization requests in the preceding six-month evaluation period.

Spectrum: Moderate Partisan Bill (Democrat 9-1)

Status: (Introduced - Dead) 2022-04-20 - print number 9908a [A09908 Detail]

Download: New_York-2021-A09908-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          9908

                   IN ASSEMBLY

                                     April 19, 2022
                                       ___________

        Introduced  by  M.  of A. McDONALD, WOERNER -- read once and referred to
          the Committee on Insurance

        AN ACT to amend the public health law, in relation  to  exemptions  from
          preauthorization requirements in certain circumstances

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

     1    Section 1. Section 4902 of the public health law is amended by  adding
     2  a new subdivision 5 to read as follows:
     3    5.  (a)  A  health  care plan that uses a preauthorization process for
     4  health care services shall not require a  health  care  professional  to
     5  obtain  preauthorization for a particular health care service if, in the
     6  most recent six-month evaluation  period,  such  health  care  plan  has
     7  approved  not  less than ninety percent of the preauthorization requests
     8  submitted by such healthcare professional for the particular health care
     9  service.
    10    (b) A health care plan shall evaluate whether a  health  care  profes-
    11  sional  qualifies  for  an  exemption from preauthorization requirements
    12  under paragraph (a) of this subdivision once every six months.
    13    (c) A health care plan may continue an exemption under  paragraph  (a)
    14  of  this  subdivision without evaluating whether the health care profes-
    15  sional qualifies for the exemption for a particular evaluation period.
    16    (d) A health care professional shall not be  required  to  request  an
    17  exemption to qualify for such exemption.
    18    (e)  A  health  care  professional's  exemption  from preauthorization
    19  requirements under paragraph (a) of this  subdivision  shall  remain  in
    20  effect until:
    21    (i)  the thirtieth day after the health care plan notifies such health
    22  care professional of such health care plan's  determination  to  rescind
    23  such  exemption  if  such  health care professional does not appeal such
    24  health care plan's determination; or
    25    (ii) if such health care professional appeals such determination,  the
    26  fifth  day after the independent review organization affirms such health
    27  care plan's determination to rescind such exemption. If  a  health  care
    28  plan  does not finalize a rescission determination, then the health care

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD14530-01-2
        A. 9908                             2

     1  professional shall be considered to have met the criteria to continue to
     2  qualify for the exemption.
     3    (f)  A health care plan may rescind an exemption from preauthorization
     4  requirements under paragraph (a) of this subdivision only:
     5    (i) during January or June of each year;
     6    (ii) if such health care plan makes a determination, on the basis of a
     7  retrospective review of a random sample of not fewer than  five  and  no
     8  more than twenty claims submitted by the health care professional during
     9  the most recent evaluation period, that less than ninety percent of such
    10  claims  for the particular health care service met the medical necessity
    11  criteria that would have been used by such health care professional when
    12  conducting preauthorization review for such health care  service  during
    13  the relevant evaluation period; and
    14    (iii) if such health care plan complies with other applicable require-
    15  ments specified in this section, including:
    16    (1)  notifying  the health care professional not less than twenty-five
    17  days before the proposed rescission is to take effect; and
    18    (2) providing with such notice the sample information used to make the
    19  determination under subparagraph (ii) of this  paragraph,  and  a  plain
    20  language  explanation of how the health care professional may appeal the
    21  determination.
    22    (g) A health care plan may deny  an  exemption  from  preauthorization
    23  requirements under paragraph (a) of this subdivision only if:
    24    (i)  the  health care professional does not have such exemption at the
    25  time of the relevant evaluation period; and
    26    (ii) such health care plan provides the health care professional  with
    27  actual  statistics  and  data  for the relevant preauthorization request
    28  evaluation period and detailed  information  sufficient  to  demonstrate
    29  that  such  health  care  professional does not meet the criteria for an
    30  exemption from preauthorization requirements for the  particular  health
    31  care service.
    32    (h)  After a final determination or review affirming the rescission or
    33  denial of an exemption for a specific health care  service  under  para-
    34  graph  (a)  of  this  subdivision,  a  health care professional shall be
    35  eligible for consideration of an exemption  for  the  same  health  care
    36  service  after  the  six-month evaluation period that follows the evalu-
    37  ation period which formed the basis of the rescission or  denial  of  an
    38  exemption.
    39    (i)  Not  later  than five days after qualifying for an exemption from
    40  preauthorization requirements under paragraph (a) of this subdivision, a
    41  health care plan shall provide to the health care professional a  notice
    42  that includes:
    43    (i)  a  statement  that such health care professional qualifies for an
    44  exemption from preauthorization requirements under paragraph (a) of this
    45  subdivision;
    46    (ii) a list of the  health  care  services  to  which  such  exemption
    47  applies; and
    48    (iii) a statement of the duration of such exemption.
    49    (j)  If  a health care professional submits a preauthorization request
    50  for a health care service under  which  such  health  care  professional
    51  qualifies  for  an  exemption  from  preauthorization requirements under
    52  paragraph (a) of this subdivision, such health care plan shall  promptly
    53  provide  a notice to such health care professional that such health care
    54  professional has qualified for an  exemption  for  preauthorization  for
    55  such health care service.
    56    (k) Nothing in this subdivision shall be construed to:
        A. 9908                             3

     1    (i)  authorize  a  health  care  professional to provide a health care
     2  service outside the scope of such health care professional's  applicable
     3  license; or
     4    (ii)  prohibit a health care plan from performing retrospective review
     5  of a health care service to section forty-nine  hundred  three  of  this
     6  title.
     7    § 2. This act shall take effect on the one hundred eightieth day after
     8  it shall have become a law.