S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   2498
 
                        2019-2020 Regular Sessions
 
                             I N  S E N A T E
 
                             January 25, 2019
                                ___________
 
 Introduced  by Sen. MARTINEZ -- read twice and ordered printed, and when
   printed to be committed to the Committee on Insurance
 
 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  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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD02684-01-9

 S. 2498                             2
 
 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.
   §  2.  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.
   § 3. This act shall take effect immediately.