S T A T E O F N E W Y O R K
________________________________________________________________________
8299
I N S E N A T E
February 10, 2022
___________
Introduced by Sen. BRESLIN -- 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 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.
LBD14525-01-2
S. 8299 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-
S. 8299 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
S. 8299 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.