S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   9086
 
                           I N  A S S E M B L Y
 
                             January 17, 2020
                                ___________
 
 Introduced by M. of A. GOTTFRIED, REYES -- read once and referred to the
   Committee on Insurance
 
 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.
                                                            LBD03578-02-0

 A. 9086                             2
 
 zation, coverage for the inpatient substance use disorder  treatment  OR
 NURSING  HOME CARE while a determination by the utilization review agent
 is pending.
   §  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.
   § 3. This act shall take effect on the ninetieth day  after  it  shall
 have become a law.