Bill Text: NY S04922 | 2015-2016 | General Assembly | Amended
Bill Title: Provides for the expedited utilization review of court ordered mental health and/or substance use disorder services.
Spectrum: Slight Partisan Bill (Republican 3-1)
Status: (Introduced - Dead) 2015-06-18 - SUBSTITUTED BY A1327A [S04922 Detail]
Download: New_York-2015-S04922-Amended.html
S T A T E O F N E W Y O R K
________________________________________________________________________
4922--A
Cal. No. 1062
2015-2016 Regular Sessions
I N S E N A T E
April 23, 2015
___________
Introduced by Sens. HANNON, LARKIN, VALESKY -- read twice and ordered
printed, and when printed to be committed to the Committee on Health
-- reported favorably from said committee, ordered to first and second
report, ordered to a third reading, amended and ordered reprinted,
retaining its place in the order of third reading
AN ACT to amend the public health law and the insurance law, in relation
to expedited utilization review of court ordered mental health and/or
substance use disorder services
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Subdivision 2 of section 4903 of the public health law, as
2 amended by section 22 of part H of chapter 60 of the laws of 2014, is
3 amended to read as follows:
4 2. (A) 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 enrollee or
7 enrollee's designee and the enrollee's health care provider by telephone
8 and in writing within three business days of receipt of the necessary
9 information. 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; [(a)] (I) whether the services are considered in-network
13 or out-of-network; [(b)] (II) and whether the enrollee will be held
14 harmless for the services and not be responsible for any payment, other
15 than any applicable co-payment or co-insurance; [(c)] (III) as applica-
16 ble, the dollar amount the health care plan will pay if the service is
17 out-of-network; and [(d)] (IV) as applicable, information explaining how
18 an enrollee may determine the anticipated out-of-pocket cost for out-of-
19 network health care services in a geographical area or zip code based
20 upon the difference between what the health care plan will reimburse for
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD06406-04-5
S. 4922--A 2
1 out-of-network health care services and the usual and customary cost for
2 out-of-network health care services.
3 (B) WITH REGARD TO INDIVIDUAL OR GROUP CONTRACTS AUTHORIZED PURSUANT
4 TO ARTICLE FORTY-FOUR OF THIS CHAPTER, FOR UTILIZATION REVIEW DETERMI-
5 NATIONS INVOLVING PROPOSED MENTAL HEALTH AND/OR SUBSTANCE USE DISORDER
6 SERVICES WHERE THE ENROLLEE OR THE ENROLLEE'S DESIGNEE HAS, IN A FORMAT
7 PRESCRIBED BY THE SUPERINTENDENT OF FINANCIAL SERVICES, CERTIFIED IN THE
8 REQUEST THAT THE PROPOSED SERVICES ARE FOR AN INDIVIDUAL WHO WILL BE
9 APPEARING, OR HAS APPEARED, BEFORE A COURT OF COMPETENT JURISDICTION AND
10 MAY BE SUBJECT TO A COURT ORDER REQUIRING SUCH SERVICES, THE UTILIZATION
11 REVIEW AGENT SHALL MAKE A DETERMINATION AND PROVIDE NOTICE OF SUCH
12 DETERMINATION TO THE ENROLLEE OR THE ENROLLEE'S DESIGNEE BY TELEPHONE
13 WITHIN SEVENTY-TWO HOURS OF RECEIPT OF THE REQUEST. WRITTEN NOTICE OF
14 THE DETERMINATION TO THE ENROLLEE OR ENROLLEE'S DESIGNEE SHALL FOLLOW
15 WITHIN THREE BUSINESS DAYS. WHERE FEASIBLE, SUCH TELEPHONIC AND WRITTEN
16 NOTICE SHALL ALSO BE PROVIDED TO THE COURT.
17 S 2. Subdivision 2 of section 4904 of the public health law, as
18 amended by chapter 41 of the laws of 2014, is amended to read as
19 follows:
20 2. A utilization review agent shall establish an expedited appeal
21 process for appeal of an adverse determination involving:
22 (a) continued or extended health care services, procedures or treat-
23 ments or additional services for an enrollee undergoing a course of
24 continued treatment prescribed by a health care provider home health
25 care services following discharge from an inpatient hospital admission
26 pursuant to subdivision three of section forty-nine hundred three of
27 this [article] TITLE; or
28 (b) an adverse determination in which the health care provider
29 believes an immediate appeal is warranted except any retrospective
30 determination[.]; OR
31 (C) POTENTIAL COURT-ORDERED MENTAL HEALTH AND/OR SUBSTANCE USE DISOR-
32 DER SERVICES PURSUANT TO PARAGRAPH (B) OF SUBDIVISION TWO OF SECTION
33 FORTY-NINE HUNDRED THREE OF THIS TITLE. Such process shall include mech-
34 anisms which facilitate resolution of the appeal including but not
35 limited to the sharing of information from the enrollee's health care
36 provider and the utilization review agent by telephonic means or by
37 facsimile. The utilization review agent shall provide reasonable access
38 to its clinical peer reviewer within one business day of receiving
39 notice of the taking of an expedited appeal. Expedited appeals shall be
40 determined within two business days of receipt of necessary information
41 to conduct such appeal except, with respect to inpatient substance use
42 disorder treatment provided pursuant to paragraph (c) of subdivision [3]
43 THREE of section [four thousand nine] FORTY-NINE hundred three of this
44 [article] TITLE, expedited appeals shall be determined within twenty-
45 four hours of receipt of such appeal. Expedited appeals which do not
46 result in a resolution satisfactory to the appealing party may be
47 further appealed through the standard appeal process, or through the
48 external appeal process pursuant to section forty-nine hundred fourteen
49 of this article as applicable. Provided that the enrollee or the
50 enrollee's health care provider files an expedited internal and external
51 appeal within twenty-four hours from receipt of an adverse determination
52 for inpatient substance use disorder treatment for which coverage was
53 provided while the initial utilization review determination was pending
54 pursuant to paragraph (c) of subdivision [3] THREE of section [four
55 thousand nine] FORTY-NINE hundred three of this [article] TITLE, a
56 utilization review agent shall not deny on the basis of medical necessi-
S. 4922--A 3
1 ty or lack of prior authorization such substance use disorder treatment
2 while a determination by the utilization review agent or external appeal
3 agent is pending.
4 S 3. Subsection (b) of section 4903 of the insurance law, as amended
5 by section 12 of part H of chapter 60 of the laws of 2014, is amended to
6 read as follows:
7 (b) (1) A utilization review agent shall make a utilization review
8 determination involving health care services which require pre-authori-
9 zation and provide notice of a determination to the insured or insured's
10 designee and the insured's health care provider by telephone and in
11 writing within three business days of receipt of the necessary informa-
12 tion. To the extent practicable, such written notification to the
13 enrollee's health care provider shall be transmitted electronically, in
14 a manner and in a form agreed upon by the parties. The notification
15 shall identify: [(1)] (I) whether the services are considered in-network
16 or out-of-network; [(2)] (II) whether the insured will be held harmless
17 for the services and not be responsible for any payment, other than any
18 applicable co-payment, co-insurance or deductible; [(3)] (III) as appli-
19 cable, the dollar amount the health care plan will pay if the service is
20 out-of-network; and [(4)] (IV) as applicable, information explaining how
21 an insured may determine the anticipated out-of-pocket cost for out-of-
22 network health care services in a geographical area or zip code based
23 upon the difference between what the health care plan will reimburse for
24 out-of-network health care services and the usual and customary cost for
25 out-of-network health care services.
26 (2) WITH REGARD TO INDIVIDUAL OR GROUP CONTRACTS AUTHORIZED PURSUANT
27 TO ARTICLE THIRTY-TWO, FORTY-THREE OR FORTY-SEVEN OF THIS CHAPTER OR
28 ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW, FOR UTILIZATION AND REVIEW
29 DETERMINATIONS INVOLVING PROPOSED MENTAL HEALTH AND/OR SUBSTANCE USE
30 DISORDER SERVICES WHERE THE INSURED OR THE INSURED'S DESIGNEE HAS, IN A
31 FORMAT PRESCRIBED BY THE SUPERINTENDENT, CERTIFIED IN THE REQUEST THAT
32 THE PROPOSED SERVICES ARE FOR AN INDIVIDUAL WHO WILL BE APPEARING, OR
33 HAS APPEARED, BEFORE A COURT OF COMPETENT JURISDICTION AND MAY BE
34 SUBJECT TO A COURT ORDER REQUIRING SUCH SERVICES, THE UTILIZATION REVIEW
35 AGENT SHALL MAKE A DETERMINATION AND PROVIDE NOTICE OF SUCH DETERMI-
36 NATION TO THE INSURED OR THE INSURED'S DESIGNEE BY TELEPHONE WITHIN
37 SEVENTY-TWO HOURS OF RECEIPT OF THE REQUEST. WRITTEN NOTICE OF THE
38 DETERMINATION TO THE INSURED OR INSURED'S DESIGNEE SHALL FOLLOW WITHIN
39 THREE BUSINESS DAYS. WHERE FEASIBLE, SUCH TELEPHONIC AND WRITTEN NOTICE
40 SHALL ALSO BE PROVIDED TO THE COURT.
41 S 4. Subsection (b) of section 4904 of the insurance law, as amended
42 by chapter 41 of the laws of 2014, is amended to read as follows:
43 (b) A utilization review agent shall establish an expedited appeal
44 process for appeal of an adverse determination involving (1) continued
45 or extended health care services, procedures or treatments or additional
46 services for an insured undergoing a course of continued treatment
47 prescribed by a health care provider or home health care services
48 following discharge from an inpatient hospital admission pursuant to
49 subsection (c) of section four thousand nine hundred three of this
50 [article or] TITLE; (2) an adverse determination in which the health
51 care provider believes an immediate appeal is warranted except any
52 retrospective determination; OR (3) POTENTIAL COURT-ORDERED MENTAL
53 HEALTH AND/OR SUBSTANCE USE DISORDER SERVICES PURSUANT TO PARAGRAPH TWO
54 OF SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS
55 TITLE. Such process shall include mechanisms which facilitate resolution
56 of the appeal including but not limited to the sharing of information
S. 4922--A 4
1 from the insured's health care provider and the utilization review agent
2 by telephonic means or by facsimile. The utilization review agent shall
3 provide reasonable access to its clinical peer reviewer within one busi-
4 ness day of receiving notice of the taking of an expedited appeal. Expe-
5 dited appeals shall be determined within two business days of receipt of
6 necessary information to conduct such appeal except, with respect to
7 inpatient substance use disorder treatment provided pursuant to para-
8 graph three of subsection (c) of section four thousand nine hundred
9 three of this [article] TITLE, expedited appeals shall be determined
10 within twenty-four hours of receipt of such appeal. Expedited appeals
11 which do not result in a resolution satisfactory to the appealing party
12 may be further appealed through the standard appeal process, or through
13 the external appeal process pursuant to section four thousand nine
14 hundred fourteen of this article as applicable. Provided that the
15 insured or the insured's health care provider files an expedited inter-
16 nal and external appeal within twenty-four hours from receipt of an
17 adverse determination for inpatient substance use disorder treatment for
18 which coverage was provided while the initial utilization review deter-
19 mination was pending pursuant to paragraph three of subsection (c) of
20 section four thousand nine hundred three of this [article] TITLE, a
21 utilization review agent shall not deny on the basis of medical necessi-
22 ty or lack of prior authorization such substance use disorder treatment
23 while a determination by the utilization review agent or external appeal
24 agent is pending.
25 S 5. This act shall take effect April 1, 2016 and shall apply to poli-
26 cies issued, renewed, or modified on and after such date.
