S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   7297
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                               April 9, 2025
                                ___________
 
 Introduced by Sens. HOYLMAN-SIGAL, ADDABBO, CLEARE, FERNANDEZ, GALLIVAN,
   GONZALEZ,  JACKSON,  KRUEGER,  LIU, MAY, RIVERA, WALCZYK, WEBB -- 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  utilization  review  program  standards  and  pre-authorization of
   health care services
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.    Paragraph  (c)  of subdivision 1 of section 4902 of the
 public health law, as added by chapter 705  of  the  laws  of  1996,  is
 amended to read as follows:
   (c) Utilization of written clinical review criteria developed pursuant
 to  a  utilization  review  plan.  SUCH  CLINICAL  REVIEW CRITERIA SHALL
 UTILIZE RECOGNIZED EVIDENCE-BASED  AND  PEER  REVIEWED  CLINICAL  REVIEW
 CRITERIA  THAT  TAKE  INTO  ACCOUNT THE NEEDS OF A TYPICAL PATIENT POPU-
 LATIONS AND DIAGNOSES;
   § 2. Paragraph (a) of subdivision 2 of  section  4903  of  the  public
 health law, as separately amended by section 13 of part YY and section 3
 of  part  KKK  of  chapter 56 of the laws of 2020, is amended to read as
 follows:
   (a) A utilization review agent shall make a utilization review  deter-
 mination  involving health care services which require pre-authorization
 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] SEVENTY-TWO HOURS of receipt of the
 necessary information, WITHIN TWENTY-FOUR HOURS OF THE RECEIPT OF NECES-
 SARY INFORMATION IF THE REQUEST IS FOR AN ENROLLEE WITH A MEDICAL CONDI-
 TION THAT PLACES THE HEALTH OF THE INSURED IN SERIOUS  JEOPARDY  WITHOUT
 THE  HEALTH  CARE  SERVICES  RECOMMENDED  BY  THE ENROLLEE'S HEALTH CARE
 PROFESSIONAL, or for  inpatient  rehabilitation  services  following  an
 inpatient  hospital  admission provided by a hospital or skilled nursing
 facility, within one business day of receipt of the  necessary  informa-
 tion.  The  notification shall identify[;]: (i) whether the services are
 
              

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD07503-01-5
 S. 7297                             2
 
 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  explain-
 ing 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 difference between what the health care plan  will  reim-
 burse  for out-of-network health care services and the usual and custom-
 ary cost for out-of-network health care  services.  AN  APPROVAL  FOR  A
 REQUEST FOR PRE-AUTHORIZATION SHALL BE VALID FOR (1) THE DURATION OF THE
 PRESCRIPTION,  INCLUDING  ANY AUTHORIZED REFILLS AND (2) THE DURATION OF
 TREATMENT FOR A SPECIFIC CONDITION AS REQUESTED BY THE ENROLLEE'S HEALTH
 CARE PROVIDER.
   § 3. Paragraph 3 of subsection (a) of section 4902  of  the  insurance
 law,  as added by chapter 705 of the laws of 1996, is amended to read as
 follows:
   (3) Utilization of written clinical review criteria developed pursuant
 to a utilization  review  plan.  SUCH  CLINICAL  REVIEW  CRITERIA  SHALL
 UTILIZE  RECOGNIZED  EVIDENCE-BASED  AND  PEER  REVIEWED CLINICAL REVIEW
 CRITERIA THAT TAKE INTO ACCOUNT THE NEEDS OF  A  TYPICAL  PATIENT  POPU-
 LATIONS AND DIAGNOSES;
   §  4.  Paragraph  1 of subsection (b) of section 4903 of the insurance
 law, as separately amended by section 16 of part YY  and  section  7  of
 part  KKK  of  chapter  56  of  the  laws of 2020, is amended to read as
 follows:
   (1) A utilization review agent shall make a utilization review  deter-
 mination  involving health care services which require pre-authorization
 and provide notice of a determination to the insured or insured's desig-
 nee and the insured's health care provider by telephone and  in  writing
 within  [three business days] SEVENTY-TWO HOURS of receipt of the neces-
 sary information, WITHIN  TWENTY-FOUR  HOURS  OF  RECEIPT  OF  NECESSARY
 INFORMATION  IF  THE  REQUEST IS FOR AN INSURED WITH A MEDICAL CONDITION
 THAT PLACES THE HEALTH OF THE INSURED IN SERIOUS  JEOPARDY  WITHOUT  THE
 HEALTH  CARE SERVICES RECOMMENDED BY THE INSURED'S HEALTH CARE PROVIDER,
 or for inpatient rehabilitation services following an inpatient hospital
 admission provided by a hospital or skilled nursing facility, within one
 business day of receipt of the necessary information.  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. AN APPROVAL OF REQUEST FOR PRE-AUTHORI-
 ZATION SHALL  BE  VALID  FOR  (1)  THE  DURATION  OF  THE  PRESCRIPTION,
 INCLUDING ANY AUTHORIZED REFILLS AND (2) THE DURATION OF TREATMENT FOR A
 SPECIFIC CONDITION REQUESTED FOR PRE-AUTHORIZATION.
   § 5. This act shall take effect on the one hundred eightieth day after
 it shall have become a law.