NY State Senate Bill 2025-S4721

Senate Bill S4721

2025-2026 Legislative Session

Provides that the failure by the utilization review agent to make a determination within certain time periods shall be deemed to be an approval of the health care services

download bill text pdf

Current Bill Status - In Senate Committee Health 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

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Feb 12, 2025	referred to health

2025-S4721 (ACTIVE) - Details

See Assembly Version of this Bill:: A4063
Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Amd §4903, Pub Health L; amd §4903, Ins L
Versions Introduced in Other Legislative Sessions:: 2021-2022: S6920
2023-2024: S3402, A6898

2025-S4721 (ACTIVE) - Summary

Provides that the failure by the utilization review agent to make a determination within certain time periods shall be deemed to be an approval of the health care services.

2025-S4721 (ACTIVE) - Sponsor Memo

                                 
BILL NUMBER: S4721

SPONSOR: FAHY
 
TITLE OF BILL:

An act to amend the public health law and the insurance law, in relation
to providing that the failure by the utilization review agent to make a
determination within certain time periods shall be deemed to be an
approval of the health care services

 
PURPOSE OR GENERAL IDEA OF BILL:

This purpose of this bill is to ensure timely determinations by health
plans regarding the provision of healthcare services, which would miti-
gate potential delays in patient care.

 
SUMMARY OF SPECIFIC PROVISIONS:

This bill would amend subdivision 7 of section 4903 of the public health
law and subsection (g) of section 4903 of the insurance law to provide
that failure by a utilization review agent to make a determination with-
in required time periods would be deemed to be an approval of the health

care service in question.

 
JUSTIFICATION:

Under current law, when a healthcare provider submits a request for
services for a health plan's enrollee, a lack of response from the
health plan results in a denial. This requires healthcare providers to
engage in a cumbersome process to appeal the denial and receive the
payment rightfully owed to the provider. Treating a non-response from a
health plan as a denial rather than as an approval, wrongly shifts the
burden to providers and forces them to appeal from silence. Notably,
after potentially lengthy and costly reviews and delays, the result is
routinely the validation of services.

Additionally, there are established timeframes within which utilization
review determinations must be made. Allowing plans to deny services by
simply not making a determination within the required timeframes creates
an incentive for insurers to delay or ignore requests. Failure of a plan
to respond to a timely claim submission should be treated as an
approval, rather than a denial. This bill would help to ensure utiliza-
tion review determinations are made in a timely manner, and would reduce
potential delays in treatment that can result in unnecessary negative
consequences in patient care.

 
PRIOR LEGISLATIVE HISTORY:

2021-22: S6920

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
This act shall take effect on the thirtieth day after it shall have
become a law.

2025-S4721 (ACTIVE) - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4721
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             February 12, 2025
                                ___________
 
 Introduced  by  Sen.  FAHY  --  read twice and ordered printed, and when
   printed to be committed to the Committee on Health
 
 AN ACT to amend the public health law and the insurance law, in relation
   to providing that the failure by the utilization review agent to  make
   a  determination  within certain time periods shall be deemed to be an
   approval of the health care services
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1. Subdivision 7 of section 4903 of the public health law, as
 amended by chapter 641 of the laws  of  2024,  is  amended  to  read  as
 follows:
   7.  Failure  by  the  utilization review agent to make a determination
 within the time periods prescribed in this section shall be deemed to be
 an [adverse determination subject to appeal pursuant to  section  forty-
 nine  hundred  four  of this title, provided, however, that] APPROVAL OF
 THE HEALTH CARE SERVICES IN QUESTION AND failure to meet such time peri-
 ods for a step therapy protocol as defined in subdivision  seven-f-three
 of  section  forty-nine hundred of this title or a step therapy protocol
 override determination pursuant to  subdivisions  three-a,  three-b  and
 three-c  of  this  section shall be deemed to be an override of the step
 therapy protocol. A utilization review agent's failure  to  comply  with
 any  of  the step therapy protocol requirements required in subdivisions
 five and six of section forty-nine hundred two of this  title  shall  be
 considered  a  basis for granting an override of the step therapy proto-
 col, absent fraud.
   § 2. Subsection (g) of section 4903 of the insurance law,  as  amended
 by chapter 641 of the laws of 2024, is amended to read as follows:
   (g)  Failure  by  the utilization review agent to make a determination
 within the time periods prescribed in this section shall be deemed to be
 an [adverse determination subject to appeal  pursuant  to  section  four
 thousand  nine  hundred four of this title, provided, however,] APPROVAL
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD08002-01-5

 S. 4721                             2
 
 OF THE HEALTH CARE SERVICES IN QUESTION AND that failure  to  meet  such
 time  periods for a step therapy protocol as defined in subsection (g-9)
 of section forty-nine hundred of this title or a step  therapy  protocol
 override determination pursuant to subsections (c-1), (c-2) and (c-3) of
 this  section  shall  be  deemed  to  be an override of the step therapy
 protocol. A utilization review agent's failure to comply with any of the
 step therapy protocol requirements required in [subsections]  PARAGRAPHS
 fifteen  and  sixteen  of  SUBSECTION  (A) OF section four thousand nine
 hundred two of this title shall be considered a basis  for  granting  an
 override of the step therapy protocol, absent fraud.
   §  3.  This  act  shall  take  effect on the same date and in the same
 manner as section 4 of chapter 641 of the laws of  2024,  takes  effect;
 provided, however, that section two of this act shall take effect on the
 same date and in the same manner as section 2 of chapter 641 of the laws
 of 2024, takes effect.

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