Bill Text: NY S02498 | 2019-2020 | General Assembly | Introduced
Bill Title: Shortens time frames during which an insurer has to determine whether a pre-authorization request is medically necessary from three business days to three days.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2020-01-08 - REFERRED TO INSURANCE [S02498 Detail]
Download: New_York-2019-S02498-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 2498 2019-2020 Regular Sessions IN SENATE January 25, 2019 ___________ Introduced by Sen. MARTINEZ -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to shortening time frames during which an insurer has to determine whether a pre-authorization request is medically necessary The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (b) of section 4903 of the insurance law, as 2 amended by chapter 371 of the laws of 2015, is amended to read as 3 follows: 4 (b) (1) A utilization review agent shall make a utilization review 5 determination involving health care services which require pre-authori- 6 zation and provide notice of a determination to the insured or insured's 7 designee and the insured's health care provider by telephone and in 8 writing within three [business] days of receipt of the necessary infor- 9 mation. To the extent practicable, such written notification to the 10 enrollee's health care provider shall be transmitted electronically, in 11 a manner and in a form agreed upon by the parties. The notification 12 shall identify: (i) whether the services are considered in-network or 13 out-of-network; (ii) whether the insured will be held harmless for the 14 services and not be responsible for any payment, other than any applica- 15 ble co-payment, co-insurance or deductible; (iii) as applicable, the 16 dollar amount the health care plan will pay if the service is out-of- 17 network; and (iv) as applicable, information explaining how an insured 18 may determine the anticipated out-of-pocket cost for out-of-network 19 health care services in a geographical area or zip code based upon the 20 difference between what the health care plan will reimburse for out-of- 21 network health care services and the usual and customary cost for out- 22 of-network health care services. 23 (2) With regard to individual or group contracts authorized pursuant 24 to article thirty-two, forty-three or forty-seven of this chapter or EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD02684-01-9S. 2498 2 1 article forty-four of the public health law, for utilization and review 2 determinations involving proposed mental health and/or substance use 3 disorder services where the insured or the insured's designee has, in a 4 format prescribed by the superintendent, certified in the request that 5 the proposed services are for an individual who will be appearing, or 6 has appeared, before a court of competent jurisdiction and may be 7 subject to a court order requiring such services, the utilization review 8 agent shall make a determination and provide notice of such determi- 9 nation to the insured or the insured's designee by telephone within 10 seventy-two hours of receipt of the request. Written notice of the 11 determination to the insured or insured's designee shall follow within 12 three business days. Where feasible, such telephonic and written notice 13 shall also be provided to the court. 14 § 2. Subdivision 2 of section 4903 of the public health law, as 15 amended by chapter 371 of the laws of 2015, is amended to read as 16 follows: 17 2. (a) A utilization review agent shall make a utilization review 18 determination involving health care services which require pre-authori- 19 zation and provide notice of a determination to the enrollee or 20 enrollee's designee and the enrollee's health care provider by telephone 21 and in writing within three [business] days of receipt of the necessary 22 information. To the extent practicable, such written notification to the 23 enrollee's health care provider shall be transmitted electronically, in 24 a manner and in a form agreed upon by the parties. The notification 25 shall identify; (i) whether the services are considered in-network or 26 out-of-network; (ii) and whether the enrollee will be held harmless for 27 the services and not be responsible for any payment, other than any 28 applicable co-payment or co-insurance; (iii) as applicable, the dollar 29 amount the health care plan will pay if the service is out-of-network; 30 and (iv) as applicable, information explaining how an enrollee may 31 determine the anticipated out-of-pocket cost for out-of-network health 32 care services in a geographical area or zip code based upon the differ- 33 ence between what the health care plan will reimburse for out-of-network 34 health care services and the usual and customary cost for out-of-network 35 health care services. 36 (b) With regard to individual or group contracts authorized pursuant 37 to article forty-four of this chapter, for utilization review determi- 38 nations involving proposed mental health and/or substance use disorder 39 services where the enrollee or the enrollee's designee has, in a format 40 prescribed by the superintendent of financial services, certified in the 41 request that the proposed services are for an individual who will be 42 appearing, or has appeared, before a court of competent jurisdiction and 43 may be subject to a court order requiring such services, the utilization 44 review agent shall make a determination and provide notice of such 45 determination to the enrollee or the enrollee's designee by telephone 46 within seventy-two hours of receipt of the request. Written notice of 47 the determination to the enrollee or enrollee's designee shall follow 48 within three business days. Where feasible, such telephonic and written 49 notice shall also be provided to the court. 50 § 3. This act shall take effect immediately.
