NY State Senate Bill 2023-S2680

Senate Bill S2680

2023-2024 Legislative Session

Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstance

download bill text pdf

Current Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Actions

View Actions

	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 22, 2024	print number 2680a
Jan 22, 2024	amend (t) and recommit to insurance
Jan 03, 2024	referred to insurance
Jun 10, 2023	committed to rules
May 24, 2023	advanced to third reading
May 23, 2023	2nd report cal.
May 22, 2023	1st report cal.1181
Jan 24, 2023	referred to insurance

Votes

- May 22, 2023 - Insurance Committee Vote
  S2680
  
  10
  
  Aye
  
  0
  
  Nay
  
  1
  
  Aye with Reservations
  
  0
  
  Absent
  
  0
  
  Excused
  
  0
  
  Abstained
  - - Insurance Committee Vote: May 22, 2023
      
      aye (10)
      
      Addabbo Jr.
      
      Breslin
      
      Cooney
      
      Harckham
      
      Helming
      
      Kennedy
      
      Martinez
      
      O'Mara
      
      Sanders Jr.
      
      Scarcella-Spanton
      
      aye wr (1)
      
      Borrello

Bill Amendments

Original

A (Active)

co-Sponsors

2023-S2680 - Details

See Assembly Version of this Bill:: A859
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §4902, Ins L; amd §4902, Pub Health L
Versions Introduced in 2021-2022 Legislative Session:: S8299, A9908

2023-S2680 - Summary

Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstances.

2023-S2680 - Sponsor Memo

                                 
BILL NUMBER: S2680

SPONSOR: BRESLIN
 
TITLE OF BILL:

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

 
PURPOSE:

To establish an exemption from preauthorization requirements for health
care professionals when their requests are regularly approved by health
insurers.

 
SUMMARY OF PROVISIONS:

Amends Subsection (a) of section 4902 of the insurance law by adding a
new paragraph 14 to establish an exemption from preauthorization
requirements for health care professionals for a particular health care
service if in the most recent 6-month evaluation period, the insurer has
approved not less than 90% of the preauthorization requests submitted by

the health care professional for the particular health care service.
Additionally:

* The insurer shall evaluate whether a health care professional quali-
fies for an exemption from preauthorization requirements once every 6
months.

* The insurer may continue an exemption without evaluating whether the
health care qualifies for the exemption for a particular evaluation
period.

* A health care professional shall not be required to request an
exemption to qualify for the exemption.

* A health care professional's exemption from preauthorization require-
ments shall remain in effect until:

* The 30th 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.

* The health care professional appeals the determination, and an inde-
pendent review organization affirms the insurer's determination to
rescind the exemption, the fifth day after the affirmation of such
determination.

* Where an insurer does not finalize a rescission determination as spec-
ified in subparagraph (vii) of this paragraph, the health care profes-
sional shall be considered to have met the criteria to continue to qual-
ify for the exemption and such exemption shall remain in effect until
the following evaluation period.

* An insurer may rescind an exemption from preauthorization require-
ments:


* During January or June of each year the insurer makes a determination,
based upon a retrospective review of a random sample of no less than 5
but no more than 20 claims submitted by the health care professional
during the most recent evaluation period, that less than 90% percent of
the claims for the particular health care service met the medical neces-
sity criteria that would have been used by the insurer when conducting
preauthorization review for the particular health care service.

* The insurer notifies the health care professional not less than 20
days before the proposed rescission is to take effect together with the
sample of claims used to make the determination and a plain language
explanation of the health care professional's right to appeal such
determination and instructions on how to initiate such appeal.

Section 2 would make corresponding changes to amends Subsection (a) of
section 4902 of the public health law.

Section 3 is the effective date.

 
JUSTIFICATION:

Many studies have detailed the growing hassles faced by health care
providers in their efforts to provide care to their patients. One such
hassle relates to prior authorization (PA) requirements, which is a
health plan cost utilization-management process that requires physicians
to get approval before a prescribed treatment, test, or medical service
can be provided to a patient. While this management tool can certainly
be appropriate in some cases, it is often imposed beyond what is neces-
sary. A survey released in December 2020, by the American Medical Asso-
ciation (AMA) detailed the consequences of excessive PA requirements,
reporting that the vast majority (91%) of respondents said PA resulted
in notable delays in care. Moreover, 87% reported that prior authori-
zation interferes with continuity of care, while 83% reported that the
number of prior authorizations required has increased over the past five
years. Adding to these concerns is that many health care services
requiring a PA are overwhelmingly approved by a health plan, yet still
are required, which imposes excessive amounts of unnecessary administra-
tive burdens on health care professionals that take time away from
delivering patient care and exacerbates the concerning trend of "burn-
out" among various health care professionals.

In response to these hassles, last year the Texas Legislature enacted a
law, also known as a "Gold Card" program, under which a payer exempts
physicians from otherwise applicable PA requirements when they regularly
receive pre-authorization for a particular health care service. This
legislation would follow the same model, where a health care provider
who receives pre-approval for a procedure at least 90% of the time, is
exempted for the next 6 months from having to receive pre-approval. At
the conclusion of the period, the health plan has the opportunity to
rescind the exemption going forward based upon a retroactive review of
claim submissions. The process has been compared to the Transportation
Security Administration's (TSA) PreCheck program, which allows frequent
airline travelers to get expedited security screening.

 
LEGISLATIVE HISTORY:

S8299 - 2021/22

 
FISCAL IMPLICATIONS:

None to the state

 
EFFECTIVE DATE:
This act shall take effect on the one hundred eightieth day after it
shall become a law.

2023-S2680 - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   2680
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                             January 24, 2023
                                ___________
 
 Introduced by Sens. BRESLIN, CLEARE, GALLIVAN, SKOUFIS -- 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.
                                                            LBD02507-01-3
 S. 2680                             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. 2680                             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. 2680                             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.

co-Sponsors

View additional co-sponsors

2023-S2680A (ACTIVE) - Details

See Assembly Version of this Bill:: A859
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §4902, Ins L; amd §4902, Pub Health L
Versions Introduced in 2021-2022 Legislative Session:: S8299, A9908

2023-S2680A (ACTIVE) - Summary

Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstances.

2023-S2680A (ACTIVE) - Sponsor Memo

                                 
BILL NUMBER: S2680A

SPONSOR: BRESLIN
 
TITLE OF BILL:

An act to amend the insurance law and the public health law, in relation
to requiring insurers and health plans to grant automatic preauthori-
zation approvals to eligible health care professionals in certain
circumstances

 
PURPOSE:

To remove unnecessary administrative requirements that impede timely
patient access to medically necessary care, delay continuity of care,
and divert health care professionals' time from delivering needed health
care, by requiring insurers and health plans to grant automatic preau-
thorization approvals to eligible health care professionals from preau-
thorization requirements under certain circumstances

 
SUMMARY OF PROVISIONS:

Amends Subsection (a) of section 4902 of the insurance law by adding a

new paragraph 14 to provide the establishment of automatic preauthori-
zation requirements for insurers and health plans to provide to health
care professionals for a particular health service as defined if in the
most recent 6-month evaluation period, the insurer has approved not less
than 90% of the preauthorization requests submitted by the health care
professional for the particular health care service.

Additionally: * The insurer shall evaluate whether a health care profes-
sional qualifies for an automatic preauthorization approval initially
based on six month evaluation period and then annually thereafter. * The
insurer may continue automatic preauthorization approval without evalu-
ating whether the health care qualifies for the exemption for a partic-
ular evaluation period. *

A health care professional shall not be required to request an automatic
preauthorization approval to qualify for the exemption. * A health care
professional's automatic preauthorization approval shall remain in
effect until: *

The 30th day after the date the insurer notifies the health care profes-
sional of the insurer's determination to rescind the automatic preau-
thorization approval pursuant to subparagraph (vii) of this paragraph if
the health care professional does not appeal such determination. *

The health care professional appeals the determination, and an independ-
ent review organization affirms the insurer's determination to rescind
the automatic preauthorization approval, the fifth day after the affir-
mation of such determination. *

Where an insurer does not finalize a rescission determination as speci-
fied in subparagraph (vii) of this paragraph, the health care profes-
sional shall be considered to have met the criteria to continue to qual-
ify for the automatic preauthorization approval and such automatic
preauthorization shall remain in effect until the following evaluation
period. *


An insurer may rescind an exemption from preauthorization requirements:
*

During January of each year the insurer makes a determination, based
upon a retrospective review for the most recent evaluation period , that
less than 90% 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. *

The insurer notifies the health care professional not less than 30 days
before the proposed rescission is to take effect together with the
sample of claims used to make the determination and a plain language
explanation of the health care professional's right to appeal such
determination and instructions on how to initiate such appeal. *

Deems health care service covered under a health care practitioners
automatic preauthorization approval to be medically necessary by virtue
of the automatic preauthorization approval and requiring claims for such
service to be paid promptly and in full. Prohibits insurers from
retroactively denying, reducing or recouping payment from health care
professional for service covered under automatic preauthorization
approval for reasons related to medical necessity. *

Prohibits insurers from retroactively denying, reducing or recouping
payment from health care professional for service for which health care
professional has qualified for the automatic preauthorization approval
unless insurer has proven the health care professional:(A) knowingly and
materially misrepresented the health care service in a request for
preauthorization or payment submitted to the insurer with the specific
intent to deceive and obtain an unlawful payment from the insurer; or
(B) failed to substantially perform the health care service. *

Requires insurers to make available and submit documentation to the
Superintendent of the Department of Financial Services that describes
the process used by the insurers for the following: (a) Determining the
specific health care service(s) for which an individual health care
professional is granted an automatic preauthorization approval; And (b)
Any other activity, policy, decision, or determination related to auto-
matic preauthorization approval Authorizes the promulgation of regu-
lations to provide for implementation. Section 2 would make correspond-
ing changes to amends Subsection (a) of section 4902 of the public
health law. Section 3 establishes the effective date.

 
JUSTIFICATION:

Many studies have detailed the growing difficulties faced by health care
providers in their efforts to provide care to their patients. One such
hassle relates to prior authorization (PA) requirements, which is a
health plan cost utilization-management process that requires physicians
to get approval before a prescribed treatment, test, or medical service
can be provided to a patient.  While this management tool can certainly
be appropriate in some cases, it is often imposed beyond what is neces-
sary. A survey released in December 2020, by the American Medical Asso-
ciation (AMA) detailed the consequences of excessive PA requirements,
reporting that the vast majority (91%) of respondents said PA resulted
in notable delays in care. Moreover, 87% reported that prior authori-
zation interferes with continuity of care, while 83% reported that the
number of prior authorizations required has increased over the past five
years. Adding to these concerns is that many health care services
requiring a PA are overwhelmingly approved by a health plan, yet still
are required, which imposes excessive amounts of unnecessary administra-
tive burdens on health care professionals that take time away from
delivering patient care and exacerbates the concerning trend of "burn-
out" among various health care professionals. In response to these
issues, the Texas Legislature recently passed and enacted a law, also
known as a "Gold Card" program, under which a payer exempts physicians
from otherwise applicable PA requirements when they regularly receive
pre-authorization for a particular health care service. Other states
have recently proposed and/or passed similar legislation including Cali-
fornia, Louisiana and most recently Michigan. This legislation would
follow a similar model, where a health care provider who receives pre
approval for a procedure at least 90% of the time, is granted automatic
preauthorization approval for the next 6 month and then annually there-
after based on review and certain conditions. The process has been
compared to the Transportation Security Administration's (TSA) PreCheck
program, which allows frequent airline travelers to get expedited secu-
rity screening. Recently several major insurers and health plans have
announced plans to launch their own gold card programs, while serious
implementation challenges and problems have arisen in states that have
enacted such laws which this legislation takes into account under the
amended version. In Texas, which is similar to the current proposed
legislation, the experience in the first year of the law has been chal-
lenging to say the least. In fact, legislation is already pending to
address the shortcomings and unintend ed consequences of the initial
law. A recent report from the Texas Medical Association states, "The
Texas Department of Insurance (TDI) reports that only 3% of physicians
and health care professionals have received gold cards because of the
current eligibility threshold, which requires physicians to submit a
minimum of five eligible prior authorization requests for a given health
care service or medication within the six-month review period." Further-
more, the Texas Medical Association guidance reported regulations imple-
menting the law tied "the definition of a particular health care service
to the issuer's website, which "means that different plans may have
different approaches to defining a service."1 The impact of prior
authorization process on patients and their health has been devastating
as a recent survey conducted by KFF found "... one-quarter of adults
whose insurance problems included prior authorization problems said
their health status declined as a direct result of problems they had
with their insurance, while one-third said it resulted in higher out-of-
pocket costs."2 1

https://www.texmed.org/GoldCardWhitePaper/ 2 https://www.kftordhealth-
reform/issuebrieficonsumer-problems- with-prior-authorization-
evidencefrom-kff-survey/

 
LEGISLATIVE HISTORY:

2021-2022: A.9908A

 
FISCAL IMPLICATIONS:

None to the state

 
EFFECTIVE DATE:
This act shall take effect on the one hundred eightieth day after it
shall become a law

2023-S2680A (ACTIVE) - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  2680--A
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                             January 24, 2023
                                ___________
 
 Introduced  by  Sens. BRESLIN, CLEARE, COONEY, GALLIVAN, SKOUFIS -- read
   twice and ordered printed, and when printed to  be  committed  to  the
   Committee on Insurance -- recommitted to the Committee on Insurance in
   accordance  with  Senate  Rule 6, sec. 8 -- committee discharged, bill
   amended, ordered reprinted as amended and recommitted to said  commit-
   tee
 
 AN ACT to amend the insurance law and the public health law, in relation
   to  requiring insurers and health plans to grant automatic preauthori-
   zation approvals to eligible  health  care  professionals  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 15 to read as follows:
   (15) ESTABLISHMENT OF AUTOMATIC PREAUTHORIZATION APPROVAL REQUIREMENTS
 FOR  INSURERS  TO  PROVIDE TO HEALTH CARE PROFESSIONALS PROVIDING HEALTH
 CARE SERVICES WHICH SHALL INCLUDE THAT:
   (I) AN INSURER THAT USES A PREAUTHORIZATION PROCESS  FOR  HEALTH  CARE
 SERVICES  SHALL  PROVIDE  AN  AUTOMATIC  PREAUTHORIZATION  APPROVAL TO A
 HEALTH CARE PROFESSIONAL  FOR  A  PARTICULAR  HEALTH  CARE  SERVICE,  AS
 DEFINED UNDER THIS TITLE INCLUDING BUT NOT LIMITED TO HEALTH CARE PROCE-
 DURES,  TREATMENTS, SERVICES, PHARMACEUTICAL PRODUCTS, SERVICES OR DURA-
 BLE MEDICAL EQUIPMENT IF, IN THE MOST RECENT SIX-MONTH EVALUATION  PERI-
 OD,  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. FOR THE PURPOSES  OF  THIS  REQUIRE-
 MENT,  A PREAUTHORIZATION REQUEST SUBMITTED DURING THE EVALUATION PERIOD
 SHALL BE CONSIDERED AND COUNTED AS A SINGLE REQUEST AND SINGLE  APPROVAL
 IF  THE  REQUEST  WAS APPROVED AT ANY POINT BETWEEN THE DATE THE REQUEST
 WAS SUBMITTED BY THE HEALTH CARE PROFESSIONAL  AND  THE  FINAL  DETERMI-
 NATION  BY  THE INSURER, INCLUDING ANY RE-REVIEW OR APPEAL PROCESS. EACH
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD02507-07-4

 S. 2680--A                          2
 
 INSURER SHALL COMPLETE ITS INITIAL EVALUATION  AND  ISSUE  ITS  DETERMI-
 NATION TO EACH HEALTH CARE PROFESSIONAL IN ITS NETWORK NO LATER THAN ONE
 HUNDRED  EIGHTY  DAYS  AFTER  THE  EFFECTIVE DATE OF THIS PARAGRAPH. THE
 AUTOMATIC  PREAUTHORIZATION  APPROVAL SHALL BECOME EFFECTIVE TWO HUNDRED
 TWENTY-FIVE DAYS AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH;
   (II) AFTER THE INITIAL EVALUATION HAS BEEN COMPLETED THE INSURER SHALL
 ANNUALLY THEREAFTER EVALUATE WHETHER A HEALTH CARE  PROFESSIONAL  QUALI-
 FIES  FOR  AN AUTOMATIC PREAUTHORIZATION APPROVAL UNDER SUBPARAGRAPH (I)
 OF THIS PARAGRAPH FOR ADDITIONAL HEALTH CARE SERVICES.  EACH  YEAR,  THE
 EVALUATION  SHALL  REVIEW  PREAUTHORIZATION  DETERMINATIONS  MADE IN THE
 FIRST SIX MONTHS OF THE YEAR. EACH INSURER SHALL ISSUE ITS DETERMINATION
 TO EACH HEALTH CARE PROFESSIONAL IN ITS NETWORK NO LATER  THAN  NOVEMBER
 FIFTEENTH TO BE EFFECTIVE JANUARY FIRST OF THE FOLLOWING YEAR;
   (III) THE INSURER MAY CONTINUE THE AUTOMATIC PREAUTHORIZATION APPROVAL
 UNDER  SUBPARAGRAPH (I) OF THIS PARAGRAPH WITHOUT EVALUATING WHETHER THE
 HEALTH  CARE  PROFESSIONAL  QUALIFIES  FOR  AUTOMATIC   PREAUTHORIZATION
 APPROVAL FOR A PARTICULAR EVALUATION PERIOD;
   (IV)  A  HEALTH  CARE PROFESSIONAL SHALL NOT BE REQUIRED TO REQUEST AN
 AUTOMATIC PREAUTHORIZATION APPROVAL TO QUALIFY FOR SUCH APPROVAL;
   (V) A HEALTH CARE PROFESSIONAL'S AUTOMATIC  PREAUTHORIZATION  APPROVAL
 UNDER  SUBPARAGRAPH  (I)  OF THIS PARAGRAPH SHALL REMAIN IN EFFECT UNTIL
 THE THIRTIETH CALENDAR DAY AFTER:
   (A) THE DATE THE INSURER NOTIFIES THE HEALTH CARE PROFESSIONAL OF  THE
 INSURER'S   DETERMINATION  TO  RESCIND  THE  AUTOMATIC  PREAUTHORIZATION
 APPROVAL 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, THE
 DATE THE INSURER NOTIFIES THE HEALTH CARE PROFESSIONAL THAT AN INDEPEND-
 ENT REVIEW ORGANIZATION HAS  AFFIRMED  THE  INSURER'S  DETERMINATION  TO
 RESCIND THE AUTOMATIC PREAUTHORIZATION APPROVAL;
   (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 AUTOMATIC PREAUTHORIZATION APPROVAL, WHICH SHALL REMAIN
 IN EFFECT UNTIL THE FOLLOWING EVALUATION PERIOD;
   (VII) AN INSURER MAY RESCIND AN  AUTOMATIC  PREAUTHORIZATION  APPROVAL
 UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH ONLY:
   (A) EFFECTIVE JANUARY OF EACH YEAR;
   (B)  IF THE INSURER MAKES A DETERMINATION ON THE BASIS OF A RETROSPEC-
 TIVE REVIEW AS SPECIFIED IN SUBPARAGRAPH (II) OF THIS PARAGRAPH FOR  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 PREAU-
 THORIZATION  REVIEW  FOR  THE  PARTICULAR HEALTH CARE SERVICE DURING THE
 RELEVANT EVALUATION 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 THIRTY CALENDAR DAYS BEFORE THE PROPOSED RESCISSION IS TO TAKE
 EFFECT,  TOGETHER  WITH  THE  SAMPLE OF CLAIMS USED TO MAKE THE DETERMI-
 NATION 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,  AN  INSURER  MAY  DENY  AN  AUTOMATIC PREAUTHORIZATION
 APPROVAL:
 S. 2680--A                          3
 
   (A) IF THE HEALTH CARE PROFESSIONAL DOES NOT HAVE THE APPROVAL 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 AUTOMATIC
 PREAUTHORIZATION APPROVAL 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 AUTOMATIC PREAUTHORIZATION APPROVAL FOR A  SPECIFIC  HEALTH
 CARE  SERVICE  UNDER THIS PARAGRAPH, A HEALTH CARE PROFESSIONAL SHALL BE
 ELIGIBLE FOR CONSIDERATION OF SUCH APPROVAL FOR  THE  SAME  HEALTH  CARE
 SERVICE  AFTER  THE  EVALUATION  PERIOD  FOLLOWING THE EVALUATION PERIOD
 WHICH FORMED THE BASIS OF THE RESCISSION OR DENIAL OF SUCH APPROVAL;
   (X) THE INSURER SHALL, NOT LATER THAN FIVE BUSINESS DAYS AFTER  DETER-
 MINING THAT A HEALTH CARE PROFESSIONAL QUALIFIES FOR AN AUTOMATIC PREAU-
 THORIZATION  APPROVAL  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
 AUTOMATIC PREAUTHORIZATION APPROVAL PURSUANT TO THIS PARAGRAPH;
   (B)  A DESCRIPTION OF THE HEALTH CARE SERVICES TO WHICH SUCH AUTOMATIC
 PREAUTHORIZATION APPLIES; AND
   (C) A STATEMENT OF THE DURATION THAT  SUCH  AUTOMATIC  APPROVAL  SHALL
 REMAIN IN EFFECT;
   (XI)  WHEN  THE  HEALTH  CARE  PROFESSIONAL SUBMITS A PREAUTHORIZATION
 REQUEST FOR A HEALTH CARE SERVICE FOR WHICH THE HEALTH CARE PROFESSIONAL
 QUALIFIES FOR AN AUTOMATIC PREAUTHORIZATION APPROVAL UNDER  SUBPARAGRAPH
 (I)  OF  THIS  PARAGRAPH,  THE INSURER SHALL PROMPTLY ISSUE AN AUTOMATIC
 PREAUTHORIZATION APPROVAL FOR SUCH HEALTH CARE SERVICE;
   (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;
   (XIII) WHEN A HEALTH CARE PROFESSIONAL PROVIDES A HEALTH CARE  SERVICE
 COVERED  BY  THE  HEALTH  CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION
 APPROVAL, THE SERVICE IS DEEMED MEDICALLY NECESSARY  BY  VIRTUE  OF  THE
 AUTOMATIC  PREAUTHORIZATION  APPROVAL.  FOR  EVERY  CLAIM SUBMITTED BY A
 HEALTH CARE PROFESSIONAL FOR SUCH SERVICE, EACH INSURER  SHALL  PROMPTLY
 PAY  THE  FULL  PAYMENT  TO  THE HEALTH CARE PROFESSIONAL. AN INSURER IS
 PROHIBITED FROM DENYING, WITHHOLDING, OR REDUCING PAYMENT  TO  A  HEALTH
 CARE  PROFESSIONAL  FOR  SUCH  HEALTH  CARE  SERVICE. AN INSURER MAY NOT
 RETROACTIVELY DENY, REDUCE, OR RECOUP PAYMENT FROM A HEALTH CARE PROFES-
 SIONAL FOR SUCH HEALTH CARE  SERVICE  FOR  REASONS  RELATED  TO  MEDICAL
 NECESSITY OR APPROPRIATENESS OF CARE;
   (XIV) AN INSURER MAY NOT RETROACTIVELY DENY, REDUCE, OR RECOUP PAYMENT
 FROM  A HEALTH CARE PROFESSIONAL FOR A HEALTH CARE SERVICE FOR WHICH THE
 HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAUTHORIZATION
 APPROVAL UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH UNLESS THE INSURER HAS
 PROVEN THAT THE HEALTH CARE PROFESSIONAL:
   (A) KNOWINGLY AND MATERIALLY MISREPRESENTED THE HEALTH CARE SERVICE IN
 A REQUEST FOR PREAUTHORIZATION OR PAYMENT SUBMITTED TO THE INSURER  WITH
 THE  SPECIFIC  INTENT TO DECEIVE AND OBTAIN AN UNLAWFUL PAYMENT FROM THE
 INSURER; OR
 S. 2680--A                          4
 
   (B) FAILED TO SUBSTANTIALLY PERFORM THE HEALTH CARE SERVICE;
   (XV)  AN  INSURER MAY NOT RETROACTIVELY DENY, REDUCE OR RECOUP PAYMENT
 FROM A HEALTH CARE PROFESSIONAL FOR A HEALTH CARE SERVICE FOR WHICH  THE
 HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAUTHORIZATION
 APPROVAL  SOLELY  ON  THE  BASIS  OF  THE  RESCISSION OF THE HEALTH CARE
 PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION APPROVAL. NOTHING HEREIN SHALL
 LIMIT A HEALTH CARE PROFESSIONAL'S ABILITY TO FILE A COMPLAINT WITH  THE
 DEPARTMENT;
   (XVI)  THE  INSURER SHALL MAKE AVAILABLE AND SUBMIT TO THE SUPERINTEN-
 DENT, AT THE SUPERINTENDENT'S REQUEST, DOCUMENTATION THAT DESCRIBES  THE
 INSURER'S PROCESS FOR:
   (A) DETERMINING THE SPECIFIC HEALTH CARE SERVICE OR SERVICES FOR WHICH
 AN  INDIVIDUAL  HEALTH  CARE PROFESSIONAL IS GRANTED AN AUTOMATIC PREAU-
 THORIZATION APPROVAL; AND
   (B) ANY OTHER ACTIVITY, POLICY, DECISION, OR DETERMINATION RELATED  TO
 AUTOMATIC PREAUTHORIZATION APPROVALS; AND
   (XVII)  THE  SUPERINTENDENT  SHALL PROMULGATE REGULATIONS TO IMPLEMENT
 THE REQUIREMENTS OF THIS SECTION AND ESTABLISH ADDITIONAL MINIMUM STAND-
 ARDS AS APPROPRIATE.
   § 2. Subdivision 1 of section 4902 of the public health law is amended
 by adding a new paragraph (m) to read as follows:
   (M) ESTABLISHMENT OF AUTOMATIC PREAUTHORIZATION APPROVAL  REQUIREMENTS
 FOR  HEALTH CARE PLANS TO PROVIDE TO 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 PROVIDE AN AUTOMATIC PREAUTHORIZATION APPROVAL TO  A
 HEALTH  CARE  PROFESSIONAL  FOR  A PARTICULAR HEALTH CARE SERVICE IF, AS
 DEFINED UNDER THIS TITLE INCLUDING BUT NOT LIMITED TO HEALTH CARE PROCE-
 DURES, TREATMENTS, SERVICES, PHARMACEUTICAL PRODUCTS, SERVICES OR  DURA-
 BLE  MEDICAL  EQUIPMENT, 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. FOR THE PURPOSES OF THIS REQUIRE-
 MENT, A PREAUTHORIZATION REQUEST SUBMITTED DURING THE EVALUATION  PERIOD
 SHALL  BE CONSIDERED AND COUNTED AS A SINGLE REQUEST AND SINGLE APPROVAL
 IF THE REQUEST WAS APPROVED AT ANY POINT BETWEEN THE  DATE  THE  REQUEST
 WAS  SUBMITTED  BY  THE  HEALTH CARE PROFESSIONAL AND THE FINAL DETERMI-
 NATION BY THE HEALTH CARE PLAN, INCLUDING ANY RE-REVIEW OR APPEAL  PROC-
 ESS.  EACH  INSURER  SHALL COMPLETE ITS INITIAL EVALUATION AND ISSUE ITS
 DETERMINATION TO EACH HEALTH CARE PROFESSIONAL IN ITS NETWORK  NO  LATER
 THAN ONE HUNDRED EIGHTY DAYS AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH.
 THE  AUTOMATIC  PREAUTHORIZATION  APPROVAL  SHALL  BECOME  EFFECTIVE TWO
 HUNDRED TWENTY-FIVE DAYS AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH;
   (II) AFTER THE INITIAL EVALUATION HAS BEEN COMPLETED THE  HEALTH  CARE
 PLAN  SHALL  ANNUALLY  THEREAFTER EVALUATE WHETHER A HEALTH CARE PROFES-
 SIONAL  QUALIFIES  FOR  AN  AUTOMATIC  PREAUTHORIZATION  APPROVAL  UNDER
 SUBPARAGRAPH  (I) OF THIS PARAGRAPH FOR ADDITIONAL HEALTH CARE SERVICES.
 EACH YEAR, THE EVALUATION SHALL REVIEW  PREAUTHORIZATION  DETERMINATIONS
 MADE  IN  THE  FIRST SIX MONTHS OF THE YEAR. EACH HEALTH CARE PLAN SHALL
 ISSUE ITS DETERMINATION TO EACH HEALTH CARE PROFESSIONAL IN ITS  NETWORK
 NO  LATER  THAN  NOVEMBER FIFTEENTH TO BE EFFECTIVE JANUARY FIRST OF THE
 FOLLOWING YEAR;
   (III) THE HEALTH CARE PLAN MAY CONTINUE THE AUTOMATIC PREAUTHORIZATION
 APPROVAL UNDER SUBPARAGRAPH (I) OF  THIS  PARAGRAPH  WITHOUT  EVALUATING
 WHETHER  THE HEALTH CARE PROFESSIONAL QUALIFIES FOR THE AUTOMATIC PREAU-
 THORIZATION APPROVAL FOR A PARTICULAR EVALUATION PERIOD;
 S. 2680--A                          5
 
   (IV) A HEALTH CARE PROFESSIONAL SHALL NOT BE REQUIRED  TO  REQUEST  AN
 AUTOMATIC PREAUTHORIZATION APPROVAL TO QUALIFY FOR SUCH APPROVAL;
   (V)  A  HEALTH CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION APPROVAL
 UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH SHALL REMAIN  IN  EFFECT  UNTIL
 THE THIRTIETH CALENDAR DAY AFTER:
   (A)  THE  DATE  THE  HEALTH CARE PLAN NOTIFIES THE HEALTH CARE PROFES-
 SIONAL OF THE HEALTH CARE PLAN'S DETERMINATION TO RESCIND THE  AUTOMATIC
 PREAUTHORIZATION  APPROVAL  PURSUANT TO SUBPARAGRAPH (VII) OF THIS PARA-
 GRAPH IF THE HEALTH CARE PROFESSIONAL  DOES  NOT  APPEAL  SUCH  DETERMI-
 NATION; OR
   (B)  WHERE THE HEALTH CARE PROFESSIONAL APPEALS THE DETERMINATION, THE
 DATE THE HEALTH CARE PLAN NOTIFIES THE HEALTH CARE PROFESSIONAL THAT  AN
 INDEPENDENT  REVIEW  ORGANIZATION  HAS  AFFIRMED  THE HEALTH CARE PLAN'S
 DETERMINATION TO RESCIND THE AUTOMATIC PREAUTHORIZATION APPROVAL;
   (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 AUTOMATIC PREAUTHORIZATION APPROVAL, WHICH
 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) EFFECTIVE JANUARY EACH YEAR;
   (B)  IF  THE  HEALTH CARE PLAN MAKES A DETERMINATION ON THE BASIS OF A
 RETROSPECTIVE REVIEW AS SPECIFIED IN SUBPARAGRAPH (II) OF THIS PARAGRAPH
 FOR THE MOST RECENT EVALUATION PERIOD THAT LESS THAN NINETY  PERCENT  OF
 THE CLAIMS FOR THE PARTICULAR HEALTH CARE SERVICE MET THE MEDICAL NECES-
 SITY  CRITERIA  THAT  WOULD  HAVE BEEN USED BY THE HEALTH CARE PLAN WHEN
 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 THIRTY CALENDAR DAYS BEFORE THE PROPOSED
 RESCISSION 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  AUTOMATIC  PREAUTHORI-
 ZATION APPROVAL:
   (A)  IF THE HEALTH CARE PROFESSIONAL DOES NOT HAVE THE APPROVAL 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
 AUTOMATIC PREAUTHORIZATION APPROVAL 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 AUTOMATIC PREAUTHORIZATION APPROVAL FOR A  SPECIFIC  HEALTH
 CARE  SERVICE  UNDER THIS PARAGRAPH, A HEALTH CARE PROFESSIONAL SHALL BE
 ELIGIBLE FOR CONSIDERATION OF SUCH APPROVAL FOR  THE  SAME  HEALTH  CARE
 SERVICE  AFTER  THE  EVALUATION  PERIOD  FOLLOWING THE EVALUATION PERIOD
 WHICH FORMED THE BASIS OF THE RESCISSION OR DENIAL OF SUCH APPROVAL;
   (X) THE HEALTH CARE PLAN SHALL, NOT  LATER  THAN  FIVE  BUSINESS  DAYS
 AFTER DETERMINING THAT A HEALTH CARE PROFESSIONAL QUALIFIES FOR AN AUTO-
 S. 2680--A                          6
 
 MATIC  PREAUTHORIZATION  APPROVAL  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
 AUTOMATIC PREAUTHORIZATION APPROVAL PURSUANT TO THIS PARAGRAPH;
   (B) A DESCRIPTION OF THE HEALTH CARE SERVICES TO WHICH SUCH  AUTOMATIC
 PREAUTHORIZATION APPROVAL APPLIES; AND
   (C)  A  STATEMENT  OF  THE DURATION THAT SUCH AUTOMATIC APPROVAL SHALL
 REMAIN IN EFFECT;
   (XI) WHEN THE HEALTH  CARE  PROFESSIONAL  SUBMITS  A  PREAUTHORIZATION
 REQUEST FOR A HEALTH CARE SERVICE FOR WHICH THE HEALTH CARE PROFESSIONAL
 QUALIFIES  FOR AN AUTOMATIC PREAUTHORIZATION APPROVAL UNDER SUBPARAGRAPH
 (I) OF THIS PARAGRAPH, THE HEALTH CARE  PLAN  SHALL  PROMPTLY  ISSUE  AN
 AUTOMATIC PREAUTHORIZATION APPROVAL FOR SUCH HEALTH CARE SERVICE;
   (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;
   (XIII) WHEN A HEALTH CARE PROFESSIONAL PROVIDES A HEALTH CARE  SERVICE
 COVERED  BY  THE  HEALTH  CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION
 APPROVAL, THE SERVICE IS DEEMED MEDICALLY NECESSARY  BY  VIRTUE  OF  THE
 AUTOMATIC  PREAUTHORIZATION  APPROVAL.  FOR  EVERY  CLAIM SUBMITTED BY A
 HEALTH CARE PROFESSIONAL FOR SUCH SERVICE, EACH HEALTH CARE  PLAN  SHALL
 PROMPTLY  PAY THE FULL PAYMENT TO THE HEALTH CARE PROFESSIONAL. A HEALTH
 CARE PLAN IS PROHIBITED FROM DENYING, WITHHOLDING, OR  REDUCING  PAYMENT
 TO  A  HEALTH  CARE  PROFESSIONAL FOR SUCH HEALTH CARE SERVICE. A HEALTH
 CARE PLAN MAY NOT RETROACTIVELY DENY, REDUCE, OR RECOUP PAYMENT  FROM  A
 HEALTH  CARE  PROFESSIONAL  FOR  SUCH  HEALTH  CARE  SERVICE FOR REASONS
 RELATED TO MEDICAL NECESSITY OR APPROPRIATENESS OF CARE;
   (XIV) A HEALTH CARE PLAN MAY NOT RETROACTIVELY DENY, REDUCE, OR RECOUP
 PAYMENT FROM A HEALTH CARE PROFESSIONAL FOR A HEALTH  CARE  SERVICE  FOR
 WHICH THE HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAU-
 THORIZATION APPROVAL UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH UNLESS THE
 HEALTH CARE PLAN HAS PROVEN THAT THE HEALTH CARE PROFESSIONAL:
   (A) KNOWINGLY AND MATERIALLY MISREPRESENTED THE HEALTH CARE SERVICE IN
 A  REQUEST  FOR PREAUTHORIZATION OR PAYMENT SUBMITTED TO THE HEALTH CARE
 PLAN WITH THE SPECIFIC INTENT TO DECEIVE AND OBTAIN AN UNLAWFUL  PAYMENT
 FROM THE HEALTH CARE PLAN; OR
   (B) FAILED TO SUBSTANTIALLY PERFORM THE HEALTH CARE SERVICE;
   (XV)  A  HEALTH CARE PLAN MAY NOT RETROACTIVELY DENY, REDUCE OR RECOUP
 PAYMENT FROM A HEALTH CARE PROFESSIONAL FOR A HEALTH  CARE  SERVICE  FOR
 WHICH THE HEALTH CARE PROFESSIONAL HAS QUALIFIED FOR AN AUTOMATIC PREAU-
 THORIZATION APPROVAL SOLELY ON THE BASIS OF THE RESCISSION OF THE HEALTH
 CARE PROFESSIONAL'S AUTOMATIC PREAUTHORIZATION APPROVAL.  NOTHING HEREIN
 SHALL  LIMIT  A  HEALTH  CARE PROFESSIONAL'S ABILITY TO FILE A COMPLAINT
 WITH THE DEPARTMENT;
   (XVI) THE HEALTH CARE PLAN SHALL MAKE  AVAILABLE  AND  SUBMIT  TO  THE
 COMMISSIONER,   AT   THE   COMMISSIONER'S  REQUEST,  DOCUMENTATION  THAT
 DESCRIBES THE HEALTH CARE PLAN'S PROCESS FOR:
   (A) DETERMINING THE SPECIFIC HEALTH CARE SERVICE OR SERVICES FOR WHICH
 AN INDIVIDUAL HEALTH CARE PROFESSIONAL IS GRANTED  AN  AUTOMATIC  PREAU-
 THORIZATION APPROVAL; AND
 S. 2680--A                          7
 
   (B)  ANY OTHER ACTIVITY, POLICY, DECISION, OR DETERMINATION RELATED TO
 AUTOMATIC PREAUTHORIZATION APPROVALS; AND
   (XVII)  THE  COMMISSIONER,  IN  CONSULTATION  WITH THE SUPERINTENDENT,
 SHALL PROMULGATE REGULATIONS  TO  IMPLEMENT  THE  REQUIREMENTS  OF  THIS
 SECTION AND ESTABLISH ADDITIONAL MINIMUM STANDARDS AS APPROPRIATE.
   § 3. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.

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Senate Bill S2680

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Sponsored By

Current Bill Status - In Senate Committee Insurance Committee

Bill Amendments

co-Sponsors

2023-S2680 - Details

2023-S2680 - Summary

2023-S2680 - Sponsor Memo

2023-S2680 - Bill Text download pdf

co-Sponsors

2023-S2680A (ACTIVE) - Details

2023-S2680A (ACTIVE) - Summary

2023-S2680A (ACTIVE) - Sponsor Memo

2023-S2680A (ACTIVE) - Bill Text download pdf

Comments