Bill Text: NY S06435 | 2021-2022 | General Assembly | Amended
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: Slight Partisan Bill (Democrat 3-1)
Status: (Introduced - Dead) 2022-06-03 - COMMITTED TO RULES [S06435 Detail]
Download: New_York-2021-S06435-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 6435--B 2021-2022 Regular Sessions IN SENATE April 28, 2021 ___________ Introduced by Sens. BRESLIN, CLEARE, GALLIVAN, KENNEDY -- read twice and ordered printed, and when printed to be committed to the Committee on Health -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- recommitted to the Committee on Health in accordance with Senate Rule 6, sec. 8 -- 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 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- EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD03897-06-2S. 6435--B 2 1 tion that places the health of the insured in serious jeopardy without 2 the health care services recommended by the enrollee's health care 3 professional, or for inpatient rehabilitation services following an 4 inpatient hospital admission provided by a hospital or skilled nursing 5 facility, within one business day of receipt of the necessary informa- 6 tion. The notification shall identify[;]: (i) whether the services are 7 considered in-network or out-of-network; (ii) and whether the enrollee 8 will be held harmless for the services and not be responsible for any 9 payment, other than any applicable co-payment or co-insurance; (iii) as 10 applicable, the dollar amount the health care plan will pay if the 11 service is out-of-network; and (iv) as applicable, information explain- 12 ing how an enrollee may determine the anticipated out-of-pocket cost for 13 out-of-network health care services in a geographical area or zip code 14 based upon the difference between what the health care plan will reim- 15 burse for out-of-network health care services and the usual and custom- 16 ary cost for out-of-network health care services. An approval for a 17 request for pre-authorization shall be valid for (1) the duration of the 18 prescription, including any authorized refills and (2) the duration of 19 treatment for a specific condition as requested by the enrollee's health 20 care provider. 21 § 3. Paragraph 3 of subsection (a) of section 4902 of the insurance 22 law, as added by chapter 705 of the laws of 1996, is amended to read as 23 follows: 24 (3) Utilization of written clinical review criteria developed pursuant 25 to a utilization review plan. Such clinical review criteria shall 26 utilize recognized evidence-based and peer reviewed clinical review 27 criteria that take into account the needs of a typical patient popu- 28 lations and diagnoses; 29 § 4. Paragraph 1 of subsection (b) of section 4903 of the insurance 30 law, as separately amended by section 16 of part YY and section 7 of 31 part KKK of chapter 56 of the laws of 2020, is amended to read as 32 follows: 33 (1) A utilization review agent shall make a utilization review deter- 34 mination involving health care services which require pre-authorization 35 and provide notice of a determination to the insured or insured's desig- 36 nee and the insured's health care provider by telephone and in writing 37 within [three business days] seventy-two hours of receipt of the neces- 38 sary information, within twenty-four hours of receipt of necessary 39 information if the request is for an insured with a medical condition 40 that places the health of the insured in serious jeopardy without the 41 health care services recommended by the insured's health care provider, 42 or for inpatient rehabilitation services following an inpatient hospital 43 admission provided by a hospital or skilled nursing facility, within one 44 business day of receipt of the necessary information. The notification 45 shall identify: (i) whether the services are considered in-network or 46 out-of-network; (ii) whether the insured will be held harmless for the 47 services and not be responsible for any payment, other than any applica- 48 ble co-payment, co-insurance or deductible; (iii) as applicable, the 49 dollar amount the health care plan will pay if the service is out-of- 50 network; and (iv) as applicable, information explaining how an insured 51 may determine the anticipated out-of-pocket cost for out-of-network 52 health care services in a geographical area or zip code based upon the 53 difference between what the health care plan will reimburse for out-of- 54 network health care services and the usual and customary cost for out- 55 of-network health care services. An approval of request for pre-authori- 56 zation shall be valid for (1) the duration of the prescription,S. 6435--B 3 1 including any authorized refills and (2) the duration of treatment for a 2 specific condition requested for pre-authorization. 3 § 5. Subsection (a) of section 3238 of the insurance law, as added by 4 chapter 451 of the laws of 2007, is amended to read as follows: 5 (a) An insurer, corporation organized pursuant to article forty-three 6 of this chapter, municipal cooperative health benefits plan certified 7 pursuant to article forty-seven of this chapter, or health maintenance 8 organization and other organizations certified pursuant to article 9 forty-four of the public health law ("health plan") shall pay claims for 10 a health care service for which a pre-authorization was required by, and 11 received from, the health plan prior to the rendering of such health 12 care service, and eligibility confirmed on the day of the service, 13 unless: 14 (1) [(i) the insured, subscriber, or enrollee was not a covered person15at the time the health care service was rendered.16(ii) Notwithstanding the provisions of subparagraph (i) of this para-17graph, a health plan shall not deny a claim on this basis if the18insured's, subscriber's or enrollee's coverage was retroactively termi-19nated more than one hundred twenty days after the date of the health20care service, provided that the claim is submitted within ninety days21after the date of the health care service. If the claim is submitted22more than ninety days after the date of the health care service, the23health plan shall have thirty days after the claim is received to deny24the claim on the basis that the insured, subscriber or enrollee was not25a covered person on the date of the health care service.26(2)] the submission of the claim with respect to an insured, subscrib- 27 er or enrollee was not timely under the terms of the applicable provider 28 contract, if the claim is submitted by a provider, or the policy or 29 contract, if the claim is submitted by the insured, subscriber or enrol- 30 lee; 31 [(3)] (2) at the time the pre-authorization was issued, the insured, 32 subscriber or enrollee had not exhausted contract or policy benefit 33 limitations based on information available to the health plan at such 34 time, but subsequently exhausted contract or policy benefit limitations 35 after authorization was issued; provided, however, that the health plan 36 shall include in the notice of determination required pursuant to 37 subsection (b) of section four thousand nine hundred three of this chap- 38 ter and subdivision two of section forty-nine hundred three of the 39 public health law that the visits authorized might exceed the limits of 40 the contract or policy and accordingly would not be covered under the 41 contract or policy; 42 [(4)] (3) the pre-authorization was based on materially inaccurate or 43 incomplete information provided by the insured, subscriber or enrollee, 44 the designee of the insured, subscriber or enrollee, or the health care 45 provider such that if the correct or complete information had been 46 provided, such pre-authorization would not have been granted; or 47 [(5) the pre-authorized service was related to a pre-existing condi-48tion that was excluded from coverage; or49(6)] (4) there is a reasonable basis supported by specific information 50 available for review by the superintendent that the insured, subscriber 51 or enrollee, the designee of the insured, subscriber or enrollee, or the 52 health care provider has engaged in fraud or abuse. 53 § 6. This act shall take effect on the ninetieth day after it shall 54 have become a law.