S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   2880
 
                        2019-2020 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 28, 2019
                                ___________
 
 Introduced by M. of A. HUNTER -- read once and referred to the Committee
   on Insurance
 
 AN  ACT to amend the insurance law, in relation to denial of coverage of
   treatment related to health care services for which  pre-authorization
   was granted
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Section 3238 of the insurance law is amended  by  adding  a
 new subsection (c-1) to read as follows:
   (C-1)  IF A HEALTH PLAN DENIES PAYMENT FOR THE TREATMENT OF CONCURRENT
 SYMPTOMS OR SIDE EFFECTS DUE  TO  LACK  OF  PRE-AUTHORIZATION  AND  SUCH
 TREATMENT  IS  RENDERED  AT  THE  SAME TIME AS A HEALTH CARE SERVICE FOR
 WHICH PRE-AUTHORIZATION WAS REQUIRED AND RECEIVED, UPON  THE  APPEAL  OF
 THE DENIAL, THE DENIAL OF ANY SUCH SERVICE SHALL BE UPHELD ONLY IF IT IS
 DETERMINED THAT:
   (1) THE TREATMENT IS NOT A COVERED BENEFIT;
   (2) THE TREATMENT WAS NOT MEDICALLY NECESSARY PURSUANT TO SECTION FOUR
 THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER OR SECTION FORTY-NINE HUNDRED
 FOUR OF THE PUBLIC HEALTH LAW;
   (3)  THE  TREATMENT  WAS  EXPERIMENTAL  OR INVESTIGATIONAL PURSUANT TO
 SECTION FOUR THOUSAND NINE HUNDRED  FOUR  OF  THIS  CHAPTER  OR  SECTION
 FORTY-NINE HUNDRED FOUR OF THE PUBLIC HEALTH LAW; OR
   (4)  ONE  OF THE CONDITIONS SET FORTH IN PARAGRAPHS ONE THROUGH SIX OF
 SUBSECTION (A) OF THIS SECTION IS MET.
   § 2. This act shall take effect on the ninetieth day  after  it  shall
 have become a law.
 
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD04761-01-9



              

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  2880--A
                                                         Cal. No. 493
 
                        2019-2020 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 28, 2019
                                ___________
 
 Introduced by M. of A. HUNTER -- read once and referred to the Committee
   on  Insurance  --  reported  and referred to the Committee on Codes --
   advanced to a third reading, passed by Assembly and delivered  to  the
   Senate,  recalled  from  the  Senate, vote reconsidered, bill amended,
   ordered reprinted, retaining its place on the order of third reading
 
 AN ACT to amend the insurance law, in relation to denial of coverage  of
   additional  or  alternative  services  or procedures related to health
   care services for which  pre-authorization  was  granted  or  did  not
   require  pre-authorization;  and  to repeal certain provisions of such
   law relating thereto
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.    Subsection  (c) of section 3238 of the insurance law is
 REPEALED and a new subsection (c) is added to read as follows:
   (C)(1) IF A HEALTH CARE PROVIDER, WHILE PROVIDING A SERVICE OR  PROCE-
 DURE  TO  TREAT  A PATIENT, DETERMINES THAT AN ADDITIONAL OR ALTERNATIVE
 SERVICE OR PROCEDURE IS NECESSARY AS PART OF SUCH TREATMENT, AND IN  THE
 SOLE  JUDGMENT OF THE HEALTH CARE PROVIDER IT IS NOT ADVISABLE TO INTER-
 RUPT THE PROVISION OF CARE TO THE PATIENT IN ORDER TO OBTAIN PRE-AUTHOR-
 IZATION FROM A HEALTH PLAN FOR THE ADDITIONAL OR ALTERNATIVE SERVICE  OR
 PROCEDURE, A DENIAL OF PAYMENT FOR THE ADDITIONAL OR ALTERNATIVE SERVICE
 OR  PROCEDURE DUE TO LACK OF PRE-AUTHORIZATION SHALL BE UPHELD ON APPEAL
 ONLY IF IT IS DETERMINED THAT:
   (I) THE ADDITIONAL OR  ALTERNATIVE  SERVICE  OR  PROCEDURE  IS  NOT  A
 COVERED BENEFIT;
   (II)  THE  ADDITIONAL  OR  ALTERNATIVE  SERVICE  OR  PROCEDURE WAS NOT
 MEDICALLY NECESSARY PURSUANT TO SECTION FOUR THOUSAND NINE HUNDRED  FOUR
 OF  THIS CHAPTER OR SECTION FORTY-NINE HUNDRED FOUR OF THE PUBLIC HEALTH
 LAW;
   (III) THE ADDITIONAL OR ALTERNATIVE SERVICE OR  PROCEDURE  WAS  EXPER-
 IMENTAL  OR  INVESTIGATIONAL  PURSUANT  TO  SECTION  FOUR  THOUSAND NINE
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                       [ ] is old law to be omitted.
                                                            LBD04761-02-9

 A. 2880--A                          2
 
 HUNDRED FOUR OF THIS CHAPTER OR SECTION FORTY-NINE HUNDRED FOUR  OF  THE
 PUBLIC HEALTH LAW; OR
   (IV)  ONE OF THE CONDITIONS SET FORTH IN PARAGRAPHS ONE THROUGH SIX OF
 SUBSECTION (A) OF THIS SECTION IS MET.
   (2) THE PROVISIONS OF THIS SUBSECTION SHALL  APPLY  TO  SITUATIONS  IN
 WHICH  PRE-AUTHORIZATION  WAS  REQUIRED  AND  RECEIVED  FOR  THE INITIAL
 SERVICE OR PROCEDURE, OR  THE  INITIAL  SERVICE  OR  PROCEDURE  DID  NOT
 REQUIRE PRE-AUTHORIZATION.
   (3)  THE  PROVISIONS  OF THIS SUBSECTION SHALL APPLY WITHOUT REGARD TO
 WHETHER THE CURRENT PROCEDURAL TERMINOLOGY (CPT) CODE FOR THE ADDITIONAL
 OR ALTERNATIVE SERVICE OR PROCEDURE IS DIFFERENT THAN THE CPT  CODE  FOR
 THE INITIAL SERVICE OR PROCEDURE.
   §  2.  This  act shall take effect on the ninetieth day after it shall
 have become a law.