S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  9908--A
 
                           I N  A S S E M B L Y
 
                              April 19, 2022
                                ___________
 
 Introduced  by  M.  of A. McDONALD, WOERNER -- read once and referred to
   the Committee on Insurance  --  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  exempting health care professionals from preauthorization require-
   ments in certain circumstances

   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Subsection  (a)  of  section 4902 of the insurance law is
 amended by  adding a new paragraph 14 to read as follows:
   (14) ESTABLISHMENT OF AN EXEMPTION FROM PREAUTHORIZATION  REQUIREMENTS
 FOR HEALTH CARE PROFESSIONALS PROVIDING HEALTH CARE SERVICES WHICH SHALL
 INCLUDE THAT:
   (I)  AN  INSURER  THAT USES A PREAUTHORIZATION PROCESS FOR HEALTH CARE
 SERVICES SHALL NOT REQUIRE A HEALTH CARE PROFESSIONAL TO  OBTAIN  PREAU-
 THORIZATION  FOR A PARTICULAR HEALTH CARE SERVICE IF, IN THE MOST RECENT
 SIX-MONTH EVALUATION PERIOD, THE INSURER  HAS  APPROVED  NOT  LESS  THAN
 NINETY PERCENT OF THE PREAUTHORIZATION REQUESTS SUBMITTED BY SUCH HEALTH
 CARE PROFESSIONAL FOR THE PARTICULAR HEALTH CARE SERVICE;
   (II)  THE  INSURER  SHALL  EVALUATE WHETHER A HEALTH CARE PROFESSIONAL
 QUALIFIES FOR AN  EXEMPTION  FROM  PREAUTHORIZATION  REQUIREMENTS  UNDER
 SUBPARAGRAPH (I) OF THIS PARAGRAPH ONCE EVERY SIX MONTHS;
   (III)  THE INSURER MAY CONTINUE AN EXEMPTION UNDER SUBPARAGRAPH (I) OF
 THIS PARAGRAPH WITHOUT EVALUATING WHETHER THE HEALTH  CARE  PROFESSIONAL
 QUALIFIES FOR THE EXEMPTION FOR A PARTICULAR EVALUATION PERIOD;
   (IV)  A  HEALTH  CARE PROFESSIONAL SHALL NOT BE REQUIRED TO REQUEST AN
 EXEMPTION TO QUALIFY FOR THE EXEMPTION;
   (V) A  HEALTH  CARE  PROFESSIONAL'S  EXEMPTION  FROM  PREAUTHORIZATION
 REQUIREMENTS  UNDER  SUBPARAGRAPH  (I) OF THIS PARAGRAPH SHALL REMAIN IN
 EFFECT UNTIL:
   (A) THE THIRTIETH DAY AFTER THE DATE THE INSURER NOTIFIES  THE  HEALTH
 CARE  PROFESSIONAL  OF  THE    INSURER'S  DETERMINATION  TO  RESCIND THE
 EXEMPTION PURSUANT TO SUBPARAGRAPH (VII) OF THIS PARAGRAPH IF THE HEALTH
 CARE PROFESSIONAL DOES NOT APPEAL SUCH DETERMINATION; OR
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
              

                                                            LBD14530-03-2
 A. 9908--A                          2
 
   (B) WHERE THE HEALTH CARE PROFESSIONAL APPEALS THE  DETERMINATION  AND
 THE  INDEPENDENT REVIEW ORGANIZATION AFFIRMS THE INSURER'S DETERMINATION
 TO RESCIND THE EXEMPTION, THE FIFTH DAY AFTER THE  AFFIRMATION  OF  SUCH
 DETERMINATION;
   (VI)  WHERE AN INSURER DOES NOT FINALIZE A RESCISSION DETERMINATION AS
 SPECIFIED IN SUBPARAGRAPH (VII)  OF  THIS  PARAGRAPH,  THE  HEALTH  CARE
 PROFESSIONAL SHALL BE CONSIDERED TO HAVE MET THE CRITERIA TO CONTINUE TO
 QUALIFY  FOR  THE  EXEMPTION  AND  SUCH EXEMPTION SHALL REMAIN IN EFFECT
 UNTIL THE FOLLOWING EVALUATION PERIOD;
   (VII) AN  INSURER  MAY  RESCIND  AN  EXEMPTION  FROM  PREAUTHORIZATION
 REQUIREMENTS UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH ONLY:
   (A) DURING JANUARY OR JUNE OF EACH YEAR; AND
   (B) THE INSURER MAKES A DETERMINATION, ON THE BASIS OF A RETROSPECTIVE
 REVIEW OF A RANDOM SAMPLE OF NOT FEWER THAN FIVE AND NO MORE THAN TWENTY
 CLAIMS  SUBMITTED BY THE HEALTH CARE PROFESSIONAL DURING THE MOST RECENT
 EVALUATION PERIOD THAT LESS THAN NINETY PERCENT OF THE  CLAIMS  FOR  THE
 PARTICULAR  HEALTH  CARE SERVICE MET THE MEDICAL NECESSITY CRITERIA THAT
 WOULD HAVE BEEN USED BY THE   INSURER WHEN  CONDUCTING  PREAUTHORIZATION
 REVIEW FOR THE PARTICULAR HEALTH CARE SERVICE DURING THE RELEVANT EVALU-
 ATION PERIOD; AND
   (C)  THE  INSURER  COMPLIES  WITH ALL OTHER APPLICABLE REQUIREMENTS OF
 THIS PARAGRAPH AND THE INSURER NOTIFIES THE HEALTH CARE PROFESSIONAL NOT
 LESS THAN TWENTY DAYS BEFORE THE PROPOSED RESCISSION IS TO TAKE  EFFECT,
 TOGETHER WITH THE SAMPLE OF CLAIMS USED TO MAKE THE DETERMINATION PURSU-
 ANT  TO CLAUSE (B) OF THIS SUBPARAGRAPH AND A PLAIN LANGUAGE EXPLANATION
 OF THE HEALTH CARE PROFESSIONAL'S RIGHT TO APPEAL SUCH DETERMINATION AND
 INSTRUCTIONS ON HOW TO INITIATE SUCH APPEAL;
   (VIII) NOTWITHSTANDING ANY CONTRARY PROVISION OF SUBPARAGRAPH  (I)  OF
 THIS  PARAGRAPH,  AN INSURER MAY DENY AN EXEMPTION FROM PREAUTHORIZATION
 REQUIREMENTS:
   (A) IF THE HEALTH CARE PROFESSIONAL DOES NOT HAVE THE EXEMPTION AT THE
 TIME OF THE RELEVANT EVALUATION PERIOD; AND
   (B) THE INSURER PROVIDES THE  HEALTH  CARE  PROFESSIONAL  WITH  ACTUAL
 STATISTICS AND DATA FOR THE RELEVANT PREAUTHORIZATION REQUEST EVALUATION
 PERIOD  AND  DETAILED  INFORMATION  SUFFICIENT  TO  DEMONSTRATE THAT THE
 HEALTH CARE PROFESSIONAL DOES NOT MEET THE  CRITERIA  FOR  AN  EXEMPTION
 PURSUANT TO SUBPARAGRAPH (I) OF THIS PARAGRAPH FOR THE PARTICULAR HEALTH
 CARE SERVICE;
   (IX) AFTER A FINAL DETERMINATION OR REVIEW AFFIRMING THE RESCISSION OR
 DENIAL  OF  AN  EXEMPTION  FOR A SPECIFIC HEALTH CARE SERVICE UNDER THIS
 PARAGRAPH, A HEALTH CARE PROFESSIONAL SHALL BE  ELIGIBLE  FOR  CONSIDER-
 ATION  OF AN EXEMPTION FOR THE SAME HEALTH CARE SERVICE AFTER THE EVALU-
 ATION PERIOD FOLLOWING THE EVALUATION PERIOD WHICH FORMED THE  BASIS  OF
 THE RESCISSION OR DENIAL OF AN EXEMPTION;
   (X)  THE  INSURER SHALL, NOT LATER THAN FIVE DAYS AFTER QUALIFYING FOR
 AN EXEMPTION PURSUANT TO SUBPARAGRAPH (I) OF THIS PARAGRAPH, PROVIDE  TO
 A HEALTH CARE PROFESSIONAL A NOTICE THAT SHALL INCLUDE:
   (A)  A  STATEMENT  THAT  THE HEALTH CARE PROFESSIONAL QUALIFIES FOR AN
 EXEMPTION PURSUANT TO THIS PARAGRAPH;
   (B) A DESCRIPTION OF THE HEALTH CARE SERVICES TO WHICH SUCH  EXEMPTION
 APPLIES; AND
   (C)  A  STATEMENT  OF THE DURATION THAT SUCH EXEMPTION SHALL REMAIN IN
 EFFECT; AND
   (XI) IN THE EVENT THAT THE HEALTH CARE PROFESSIONAL SUBMITS  A  PREAU-
 THORIZATION  REQUEST FOR A HEALTH CARE SERVICE FOR WHICH THE HEALTH CARE
 PROFESSIONAL QUALIFIES FOR AN EXEMPTION FROM  PREAUTHORIZATION  REQUIRE-
 A. 9908--A                          3
 
 MENTS  UNDER  SUBPARAGRAPH  (I)  OF  THIS PARAGRAPH,   THE INSURER SHALL
 PROMPTLY NOTIFY SUCH HEALTH CARE  PROFESSIONAL  THAT  SUCH  HEALTH  CARE
 PROFESSIONAL HAS QUALIFIED FOR AN EXEMPTION FOR SUCH HEALTH CARE SERVICE
 IN  ACCORDANCE  WITH  THE REQUIREMENTS OF SUBPARAGRAPH (X) OF THIS PARA-
 GRAPH.
   (XII) NOTHING IN THIS PARAGRAPH MAY BE CONSTRUED TO: (A)  AUTHORIZE  A
 HEALTH  CARE  PROFESSIONAL  TO PROVIDE A HEALTH CARE SERVICE OUTSIDE THE
 SCOPE OF SUCH HEALTH CARE  PROFESSIONAL'S  APPLICABLE  LICENSE;  OR  (B)
 PROHIBIT  A HEALTH INSURER FROM PERFORMING A RETROSPECTIVE REVIEW OF THE
 HEALTH CARE SERVICE PURSUANT TO SECTION FORTY-NINE HUNDRED THREE OF THIS
 TITLE.
   § 2. Subdivision 1 of section 4902 of the public health law is amended
 by adding a new paragraph (l) to read as follows:
   (L) ESTABLISHMENT OF AN EXEMPTION FROM  PREAUTHORIZATION  REQUIREMENTS
 FOR  HEALTH  CARE  PROFESSIONALS  PROVIDING CERTAIN HEALTH CARE SERVICES
 WHICH SHALL INCLUDE THAT:
   (I) A HEALTH CARE PLAN THAT USES A PREAUTHORIZATION PROCESS FOR HEALTH
 CARE SERVICES SHALL NOT REQUIRE A HEALTH  CARE  PROFESSIONAL  TO  OBTAIN
 PREAUTHORIZATION  FOR  A  PARTICULAR HEALTH CARE SERVICE IF, IN THE MOST
 RECENT SIX-MONTH EVALUATION PERIOD, THE HEALTH CARE  PLAN  HAS  APPROVED
 NOT  LESS THAN NINETY PERCENT OF THE PREAUTHORIZATION REQUESTS SUBMITTED
 BY SUCH HEALTH CARE PROFESSIONAL FOR THE PARTICULAR HEALTH CARE SERVICE;
   (II) SUCH HEALTH CARE  PLAN  SHALL  EVALUATE  WHETHER  A  HEALTH  CARE
 PROFESSIONAL  QUALIFIES  FOR AN EXEMPTION FROM PREAUTHORIZATION REQUIRE-
 MENTS UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH ONCE EVERY SIX MONTHS;
   (III) THE HEALTH CARE PLAN MAY CONTINUE AN  EXEMPTION  UNDER  SUBPARA-
 GRAPH  (I)  OF THIS PARAGRAPH WITHOUT EVALUATING WHETHER THE HEALTH CARE
 PROFESSIONAL QUALIFIES FOR THE EXEMPTION  FOR  A  PARTICULAR  EVALUATION
 PERIOD;
   (IV)  A  HEALTH  CARE PROFESSIONAL SHALL NOT BE REQUIRED TO REQUEST AN
 EXEMPTION TO QUALIFY FOR THE EXEMPTION UNDER THIS PARAGRAPH;
   (V) A  HEALTH  CARE  PROFESSIONAL'S  EXEMPTION  FROM  PREAUTHORIZATION
 REQUIREMENTS  UNDER  SUBPARAGRAPH  (I) OF THIS PARAGRAPH SHALL REMAIN IN
 EFFECT UNTIL:
   (A) THE THIRTIETH DAY AFTER THE DATE THE HEALTH CARE PLAN NOTIFIES THE
 HEALTH CARE PROFESSIONAL OF THE   HEALTH CARE  PLAN'S  DETERMINATION  TO
 RESCIND  THE  EXEMPTION PURSUANT TO SUBPARAGRAPH (VII) OF THIS PARAGRAPH
 IF THE HEALTH CARE PROFESSIONAL DOES NOT APPEAL SUCH DETERMINATION; OR
   (B) WHERE THE HEALTH CARE PROFESSIONAL APPEALS THE  DETERMINATION  AND
 THE  INDEPENDENT  REVIEW  ORGANIZATION  AFFIRMS  THE  HEALTH CARE PLAN'S
 DETERMINATION TO RESCIND THE EXEMPTION, THE FIFTH DAY AFTER THE AFFIRMA-
 TION OF SUCH DETERMINATION;
   (VI) WHERE A HEALTH CARE PLAN DOES NOT FINALIZE A RESCISSION  DETERMI-
 NATION  AS SPECIFIED IN SUBPARAGRAPH (VII) OF THIS PARAGRAPH, THE HEALTH
 CARE PROFESSIONAL SHALL BE  CONSIDERED  TO  HAVE  MET  THE  CRITERIA  TO
 CONTINUE TO QUALIFY FOR THE EXEMPTION AND SUCH EXEMPTION SHALL REMAIN IN
 EFFECT UNTIL THE FOLLOWING EVALUATION PERIOD;
   (VII)  A  HEALTH  CARE  PLAN MAY RESCIND AN EXEMPTION FROM PREAUTHORI-
 ZATION REQUIREMENTS UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH ONLY:
   (A) DURING JANUARY OR JUNE OF EACH YEAR; AND
   (B) THE HEALTH CARE PLAN MAKES A DETERMINATION,  ON  THE  BASIS  OF  A
 RETROSPECTIVE  REVIEW  OF  A RANDOM SAMPLE OF NOT FEWER THAN FIVE AND NO
 MORE THAN TWENTY CLAIMS SUBMITTED BY THE HEALTH CARE PROFESSIONAL DURING
 THE MOST RECENT EVALUATION PERIOD THAT LESS THAN NINETY PERCENT  OF  THE
 CLAIMS  FOR THE PARTICULAR HEALTH CARE SERVICE MET THE MEDICAL NECESSITY
 CRITERIA THAT WOULD HAVE BEEN  USED  BY  THE    HEALTH  CARE  PLAN  WHEN
 A. 9908--A                          4

 CONDUCTING  PREAUTHORIZATION  REVIEW  FOR  THE  PARTICULAR  HEALTH  CARE
 SERVICE DURING THE RELEVANT EVALUATION PERIOD; AND
   (C)  THE  HEALTH CARE PLAN COMPLIES WITH ALL OTHER APPLICABLE REQUIRE-
 MENTS OF THIS PARAGRAPH AND THE HEALTH CARE  PLAN  NOTIFIES  THE  HEALTH
 CARE  PROFESSIONAL NOT LESS THAN TWENTY DAYS BEFORE THE PROPOSED RESCIS-
 SION IS TO TAKE EFFECT, TOGETHER WITH THE SAMPLE OF CLAIMS USED TO  MAKE
 THE  DETERMINATION  PURSUANT  TO  CLAUSE  (B) OF THIS SUBPARAGRAPH AND A
 PLAIN LANGUAGE EXPLANATION OF THE HEALTH CARE  PROFESSIONAL'S  RIGHT  TO
 APPEAL  SUCH  DETERMINATION  AND  INSTRUCTIONS  ON  HOW TO INITIATE SUCH
 APPEAL;
   (VIII) NOTWITHSTANDING ANY CONTRARY PROVISION OF SUBPARAGRAPH  (I)  OF
 THIS PARAGRAPH, A HEALTH CARE PLAN MAY DENY AN EXEMPTION FROM PREAUTHOR-
 IZATION REQUIREMENTS:
   (A) IF THE HEALTH CARE PROFESSIONAL DOES NOT HAVE THE EXEMPTION AT THE
 TIME OF THE RELEVANT EVALUATION PERIOD; AND
   (B)  THE  HEALTH  CARE PLAN PROVIDES THE HEALTH CARE PROFESSIONAL WITH
 ACTUAL STATISTICS AND DATA FOR  THE  RELEVANT  PREAUTHORIZATION  REQUEST
 EVALUATION  PERIOD  AND  DETAILED  INFORMATION SUFFICIENT TO DEMONSTRATE
 THAT THE HEALTH CARE PROFESSIONAL DOES NOT  MEET  THE  CRITERIA  FOR  AN
 EXEMPTION PURSUANT TO SUBPARAGRAPH (I) OF THIS PARAGRAPH FOR THE PARTIC-
 ULAR HEALTH CARE SERVICE;
   (IX) AFTER A FINAL DETERMINATION OR REVIEW AFFIRMING THE RESCISSION OR
 DENIAL  OF  AN  EXEMPTION  FOR A SPECIFIC HEALTH CARE SERVICE UNDER THIS
 PARAGRAPH, A HEALTH CARE PROFESSIONAL SHALL BE  ELIGIBLE  FOR  CONSIDER-
 ATION  OF AN EXEMPTION FOR THE SAME HEALTH CARE SERVICE AFTER THE EVALU-
 ATION PERIOD FOLLOWING THE EVALUATION PERIOD WHICH FORMED THE  BASIS  OF
 THE RESCISSION OR DENIAL OF AN EXEMPTION;
   (X)  THE HEALTH CARE PLAN SHALL, NOT LATER THAN FIVE DAYS AFTER QUALI-
 FYING FOR AN EXEMPTION PURSUANT TO SUBPARAGRAPH (I) OF  THIS  PARAGRAPH,
 PROVIDE TO A HEALTH CARE PROFESSIONAL A NOTICE THAT SHALL INCLUDE:
   (A)  A  STATEMENT  THAT  THE HEALTH CARE PROFESSIONAL QUALIFIES FOR AN
 EXEMPTION PURSUANT TO THIS PARAGRAPH;
   (B) A DESCRIPTION OF THE HEALTH CARE SERVICES TO WHICH SUCH  EXEMPTION
 APPLIES; AND
   (C)  A  STATEMENT  OF THE DURATION THAT SUCH EXEMPTION SHALL REMAIN IN
 EFFECT; AND
   (XI) IN THE EVENT THAT THE HEALTH CARE PROFESSIONAL SUBMITS  A  PREAU-
 THORIZATION  REQUEST FOR A HEALTH CARE SERVICE FOR WHICH THE HEALTH CARE
 PROFESSIONAL QUALIFIES FOR AN EXEMPTION FROM  PREAUTHORIZATION  REQUIRE-
 MENTS  UNDER  SUBPARAGRAPH  (I) OF THIS PARAGRAPH,  THE HEALTH CARE PLAN
 SHALL PROMPTLY NOTIFY SUCH HEALTH CARE  PROFESSIONAL  THAT  SUCH  HEALTH
 CARE  PROFESSIONAL  HAS  QUALIFIED FOR AN EXEMPTION FOR SUCH HEALTH CARE
 SERVICE IN ACCORDANCE WITH THE REQUIREMENTS OF SUBPARAGRAPH (X) OF  THIS
 PARAGRAPH.
   (XII) NOTHING IN THIS PARAGRAPH SHALL BE CONSTRUED TO: (A) AUTHORIZE A
 HEALTH  CARE  PROFESSIONAL  TO PROVIDE A HEALTH CARE SERVICE OUTSIDE THE
 SCOPE OF SUCH HEALTH CARE PROFESSIONAL'S APPLICABLE  LICENSE;    OR  (B)
 PROHIBIT  A  HEALTH  CARE PLAN FROM PERFORMING A RETROSPECTIVE REVIEW OF
 THE HEALTH CARE SERVICE PURSUANT TO SECTION FORTY-NINE HUNDRED THREE  OF
 THIS TITLE.
   § 3. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.