S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  6492

                            I N  S E N A T E

                            January 20, 2016
                               ___________

Introduced  by  Sen.  HANNON -- read twice and ordered printed, and when
  printed to be committed to the Committee on Health

AN ACT to amend the public health law and the insurance law, in relation
  to utilization review of coverage of nursing home  care  following  an
  inpatient hospital admission

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Paragraphs (a) and (c) of subdivision 3 of section 4903  of
the  public  health  law,  paragraph (a) as amended and paragraph (c) as
added by chapter 41 of the laws of 2014, are amended to read as follows:
  (a) A utilization review agent shall make  a  determination  involving
continued  or  extended health care services, additional services for an
enrollee undergoing a course of  continued  treatment  prescribed  by  a
health  care  provider, or requests for inpatient substance use disorder
treatment, OR NURSING HOME CARE or home health care  services  following
an inpatient hospital admission, and shall provide notice of such deter-
mination to the enrollee or the enrollee's designee, which may be satis-
fied  by notice to the enrollee's health care provider, by telephone and
in writing within one business day of receipt of the necessary  informa-
tion  except,  with  respect  to  home health care services following an
inpatient hospital admission, within seventy-two hours of receipt of the
necessary information when the day subsequent to the request falls on  a
weekend  or  holiday and except, with respect to inpatient substance use
disorder treatment OR NURSING HOME CARE,  within  twenty-four  hours  of
receipt  of  the  request  for services when the request is submitted at
least twenty-four hours prior to discharge from an inpatient  admission.
Notification  of continued or extended services shall include the number
of extended services approved, the new total of approved  services,  the
date of onset of services and the next review date.
  (c)  Provided that a request for inpatient treatment for substance use
disorder OR NURSING HOME CARE is submitted  to  the  utilization  review
agent  at  least  twenty-four hours prior to discharge from an inpatient
admission pursuant to this subdivision, a utilization review agent shall
not deny, on the basis of medical necessity or lack  of  prior  authori-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
              

                                                           LBD13384-02-6

S. 6492                             2

zation,  coverage  for the inpatient substance use disorder treatment OR
NURSING HOME CARE while a determination by the utilization review  agent
is pending.
  S  2.  Paragraphs  1  and  3  of subsection (c) of section 4903 of the
insurance law, paragraph 1 as amended and paragraph 3 as added by  chap-
ter 41 of the laws of 2014, are amended to read as follows:
  (1)  A  utilization  review agent shall make a determination involving
continued or extended health care services, additional services  for  an
insured  undergoing  a  course  of  continued  treatment prescribed by a
health care provider, or requests for inpatient substance  use  disorder
treatment,  OR  NURSING HOME CARE or home health care services following
an inpatient hospital admission, and shall provide notice of such deter-
mination to the insured or the insured's designee, which may  be  satis-
fied  by  notice to the insured's health care provider, by telephone and
in writing within one business day of receipt of the necessary  informa-
tion  except,  with  respect  to  home health care services following an
inpatient hospital admission, within seventy-two hours of receipt of the
necessary information when the day subsequent to the request falls on  a
weekend  or  holiday and except, with respect to inpatient substance use
disorder treatment OR NURSING HOME CARE,  within  twenty-four  hours  of
receipt  of  the  request  for services when the request is submitted at
least twenty-four hours prior to discharge from an inpatient  admission.
Notification  of continued or extended services shall include the number
of extended services approved, the new total of approved  services,  the
date of onset of services and the next review date.
  (3)  Provided that a request for inpatient treatment for substance use
disorder OR NURSING HOME CARE is submitted  to  the  utilization  review
agent  at  least  twenty-four hours prior to discharge from an inpatient
admission pursuant to this subsection, a utilization review agent  shall
not  deny,  on  the basis of medical necessity or lack of prior authori-
zation, coverage for the inpatient substance use disorder  treatment  OR
NURSING  HOME CARE while a determination by the utilization review agent
is pending.
  S 3. This act shall take effect on the ninetieth day  after  it  shall
have become a law.