Bill Text: NY S03400 | 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 12-2)

Status: (Introduced) 2024-06-03 - PRINT NUMBER 3400A [S03400 Detail]

Download: New_York-2023-S03400-Amended.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                         3400--A

                               2023-2024 Regular Sessions

                    IN SENATE

                                    January 31, 2023
                                       ___________

        Introduced  by  Sens.  BRESLIN,  ADDABBO,  CLEARE,  FERNANDEZ, GALLIVAN,
          GONZALEZ, JACKSON, KRUEGER, LIU, MAY, RIVERA, WALCZYK,  WEBB  --  read
          twice  and  ordered  printed,  and when printed to be committed to the
          Committee on Health -- recommitted  to  the  Committee  on  Health  in
          accordance  with Senate Rule 6, sec. 8 -- reported favorably from said
          committee and committed to  the  Committee  on  Finance  --  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
    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.
                                                                   LBD08333-03-4
        S. 3400--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-
        S. 3400--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. This act shall take effect on the one hundred eightieth day after
     5  it shall have become a law.