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

                                 1397--A

                       2015-2016 Regular Sessions

                            I N  S E N A T E

                            January 12, 2015
                               ___________

Introduced  by Sen. CARLUCCI -- read twice and ordered printed, and when
  printed to be committed to the Committee on Insurance  --  recommitted
  to the Committee on Insurance 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 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:

  Section 1. Subsection (b) of section 4903 of  the  insurance  law,  as
amended  by  section  12 of part H of chapter 60 of the laws of 2014, is
amended to read as follows:
  (b) A utilization review agent shall make a utilization review  deter-
mination  involving health care services which require pre-authorization
and provide notice of a determination to the insured or insured's desig-
nee and the insured's health care provider by telephone and  in  writing
within three [business] days of receipt of the necessary information. To
the  extent  practicable,  such  written  notification to the enrollee's
health care provider shall be transmitted electronically,  in  a  manner
and  in a form agreed upon by the parties.  The notification shall iden-
tify: (1) whether the services are considered in-network or  out-of-net-
work; (2) whether the insured will be held harmless for the services and
not  be  responsible  for any payment, other than any applicable co-pay-
ment, co-insurance or deductible; (3) as applicable, the  dollar  amount
the  health care plan will pay if the service is out-of-network; and (4)
as applicable, information explaining how an insured may  determine  the
anticipated  out-of-pocket  cost for out-of-network health care services
in a geographical area or zip code based  upon  the  difference  between
what  the health care plan will reimburse for out-of-network health care

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD03427-03-6

              

S. 1397--A                          2

services and the usual and customary cost for out-of-network health care
services.
  S 1-a. Subsection (b) of section 4903 of the insurance law, as amended
by chapter 371 of the laws of 2015, is amended to read as follows:
  (b)  (1)  A  utilization  review agent shall make a utilization review
determination involving health care services which require  pre-authori-
zation and provide notice of a determination to the insured or insured's
designee  and  the  insured's  health  care provider by telephone and in
writing within three [business] days of receipt of the necessary  infor-
mation.  To  the  extent  practicable,  such written notification to the
enrollee's health care provider shall be transmitted electronically,  in
a  manner  and  in  a form agreed upon by the parties.  The notification
shall identify: (i) whether the services are  considered  in-network  or
out-of-network;  (ii)  whether the insured will be held harmless for the
services and not be responsible for any payment, other than any applica-
ble co-payment, co-insurance or deductible;  (iii)  as  applicable,  the
dollar  amount  the  health care plan will pay if the service is out-of-
network; and (iv) as applicable, information explaining how  an  insured
may  determine  the  anticipated  out-of-pocket  cost for out-of-network
health care services in a geographical area or zip code based  upon  the
difference  between what the health care plan will reimburse for out-of-
network health care services and the usual and customary cost  for  out-
of-network health care services.
  (2)  With  regard to individual or group contracts authorized pursuant
to article thirty-two, forty-three or forty-seven  of  this  chapter  or
article  forty-four of the public health law, for utilization and review
determinations involving proposed mental  health  and/or  substance  use
disorder  services where the insured or the insured's designee has, in a
format prescribed by the superintendent, certified in the  request  that
the  proposed  services  are for an individual who will be appearing, or
has appeared, before a  court  of  competent  jurisdiction  and  may  be
subject to a court order requiring such services, the utilization review
agent  shall  make  a  determination and provide notice of such determi-
nation to the insured or the  insured's  designee  by  telephone  within
seventy-two  hours  of  receipt  of  the  request. Written notice of the
determination to the insured or insured's designee shall  follow  within
three  business days. Where feasible, such telephonic and written notice
shall also be provided to the court.
  S 2. Subdivision 2 of section  4903  of  the  public  health  law,  as
amended  by  section  22 of part H of chapter 60 of the laws of 2014, is
amended to read as follows:
  2. A utilization review agent shall make a utilization review determi-
nation involving health care services  which  require  pre-authorization
and  provide  notice  of  a  determination to the enrollee or enrollee's
designee and the enrollee's health care provider  by  telephone  and  in
writing  within three [business] days of receipt of the necessary infor-
mation. To the extent practicable,  such  written  notification  to  the
enrollee's  health care provider shall be transmitted electronically, in
a manner and in a form agreed upon by the  parties.    The  notification
shall  identify;  (a)  whether the services are considered in-network or
out-of-network; (b) and whether the enrollee will be held  harmless  for
the  services  and  not  be  responsible for any payment, other than any
applicable co-payment or co-insurance; (c)  as  applicable,  the  dollar
amount  the  health care plan will pay if the service is out-of-network;
and (d) as applicable, information explaining how an enrollee may deter-
mine the anticipated out-of-pocket cost for out-of-network  health  care

S. 1397--A                          3

services  in  a  geographical area or zip code based upon the difference
between what the health care  plan  will  reimburse  for  out-of-network
health care services and the usual and customary cost for out-of-network
health care services.
  S  2-a.  Subdivision  2  of  section 4903 of the public health law, as
amended by chapter 371 of the laws  of  2015,  is  amended  to  read  as
follows:
  2.  (a)  A  utilization  review  agent shall make a utilization review
determination involving health care services which require  pre-authori-
zation  and  provide  notice  of  a  determination  to  the  enrollee or
enrollee's designee and the enrollee's health care provider by telephone
and in writing within three [business] days of receipt of the  necessary
information. To the extent practicable, such written notification to the
enrollee's  health care provider shall be transmitted electronically, in
a manner and in a form agreed upon by the  parties.    The  notification
shall  identify;  (i)  whether the services are considered in-network or
out-of-network; (ii) and whether the enrollee will be held harmless  for
the  services  and  not  be  responsible for any payment, other than any
applicable co-payment or co-insurance; (iii) as applicable,  the  dollar
amount  the  health care plan will pay if the service is out-of-network;
and (iv) as applicable,  information  explaining  how  an  enrollee  may
determine  the  anticipated out-of-pocket cost for out-of-network health
care services in a geographical area or zip code based upon the  differ-
ence between what the health care plan will reimburse for out-of-network
health care services and the usual and customary cost for out-of-network
health care services.
  (b)  With  regard to individual or group contracts authorized pursuant
to article forty-four of this chapter, for utilization  review  determi-
nations  involving  proposed mental health and/or substance use disorder
services where the enrollee or the enrollee's designee has, in a  format
prescribed by the superintendent of financial services, certified in the
request  that  the  proposed  services are for an individual who will be
appearing, or has appeared, before a court of competent jurisdiction and
may be subject to a court order requiring such services, the utilization
review agent shall make a  determination  and  provide  notice  of  such
determination  to  the  enrollee or the enrollee's designee by telephone
within seventy-two hours of receipt of the request.  Written  notice  of
the  determination  to  the enrollee or enrollee's designee shall follow
within three business days. Where feasible, such telephonic and  written
notice shall also be provided to the court.
  S  3.  This act shall take effect immediately, provided, however, that
sections one-a and two-a of this act shall take effect on the same  date
and in the same manner as chapter 371 of the laws of 2015, takes effect.