Bill Text: NY A00729 | 2009-2010 | General Assembly | Introduced

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Bill Title: An act to amend the public health law and the insurance law, in relation to clarifying the grounds for an external appeal based on medical necessity

Spectrum: Partisan Bill (Democrat 25-1)

Status: (Engrossed - Dead) 2010-02-01 - REFERRED TO HEALTH [A00729 Detail]

Download: New_York-2009-A00729-Introduced.html

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                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                          729
                              2009-2010 Regular Sessions
                                 I N  A S S E M B L Y
                                      (PREFILED)
                                    January 7, 2009
                                      ___________
       Introduced  by  M.  of A. GOTTFRIED, BING, CHRISTENSEN, DINOWITZ, GALEF,
         PEOPLES-STOKES, MAGNARELLI, PAULIN, HOOPER, PHEFFER, FIELDS --  Multi-
         Sponsored  by  -- M.   of A. CYMBROWITZ, GLICK, HIKIND, JOHN, KELLNER,
         LIFTON, McENENY, J. MILLER, J. RIVERA, P. RIVERA,  SCARBOROUGH,  SWEE-
         NEY, TITUS, TOWNS, WEISENBERG -- read once and referred to the Commit-
         tee on Health
       AN ACT to amend the public health law and the insurance law, in relation
         to  clarifying  the  grounds  for  an external appeal based on medical
         necessity
         THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
       BLY, DO ENACT AS FOLLOWS:
    1    Section  1.  Legislative  findings  and intent. Where there is a sound
    2  medical and scientific basis for a health care service or  procedure,  a
    3  patient should not be denied access to that care.
    4    This legislation provides, in the external appeal process, that, where
    5  a  health  care  plan denies coverage on grounds of "medical necessity",
    6  the insured shall have the opportunity to demonstrate,  through  his  or
    7  her health care professional, based on applicable medical and scientific
    8  evidence,  the  patient's medical record, and any other patient informa-
    9  tion, that the proposed health service or treatment is likely to be more
   10  beneficial than any standard treatment or treatments for  the  patient's
   11  condition or disease.
   12    This  legislation  does  not  require  a health care plan to cover any
   13  health care service or treatment that would not otherwise be  a  covered
   14  benefit for the insured.
   15    S  2.  Subparagraph  (A)  of paragraph (d) of subdivision 2 of section
   16  4914 of the public health law, as added by chapter 586 of  the  laws  of
   17  1998, is amended to read as follows:
   18    (A)  MEDICAL  NECESSITY.  For  external  appeals requested pursuant to
   19  paragraph (a) of subdivision two of section forty-nine  hundred  ten  of
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
       A                                                          LBD01102-01-9
       A. 729                              2
    1  this  title,  the  external  appeal  agent  shall review the utilization
    2  review agent's final adverse determination and, in accordance  with  the
    3  provisions  of  this title, shall make a determination as to whether the
    4  health care plan acted reasonably and with sound medical judgment and in
    5  the  best  interest of the patient. When the external appeal agent makes
    6  its determination, it shall consider the clinical standards of the plan,
    7  the information provided concerning the patient, the  attending  [physi-
    8  cian's] HEALTH CARE PROFESSIONAL'S recommendation, and applicable gener-
    9  ally  accepted  practice guidelines developed by the federal government,
   10  national or professional [medical] societies, boards  and  associations.
   11  WHERE APPLICABLE, THE APPEAL SHALL BE GRANTED IF, AND TO THE EXTENT, THE
   12  EXTERNAL  APPEAL AGENT DETERMINES, UPON REVIEW OF THE APPLICABLE MEDICAL
   13  AND SCIENTIFIC EVIDENCE, THE PATIENT'S MEDICAL  RECORD,  AND  ANY  OTHER
   14  PERTINENT  INFORMATION, THAT THE PROPOSED HEALTH SERVICE OR TREATMENT IS
   15  LIKELY TO BE MORE BENEFICIAL THAN ANY STANDARD TREATMENT  OR  TREATMENTS
   16  FOR  THE PATIENT'S CONDITION OR DISEASE OR NO TREATMENT; IF THE SPECIFIC
   17  HEALTH SERVICE OR TREATMENT RECOMMENDED BY THE HEALTH CARE  PROFESSIONAL
   18  WOULD  NOT  OTHERWISE  BE  EXCLUDED  FROM  COVERAGE  UNDER THE POLICY ON
   19  GROUNDS OTHER THAN MEDICAL NECESSITY.
   20    Provided that such determination shall:
   21    (i) be conducted only by one or a greater odd number of clinical  peer
   22  reviewers,
   23    (ii)  be  accompanied  by a notice of appeal determination which shall
   24  include the reasons for the determination; provided, however, that where
   25  the final adverse determination is upheld on appeal,  the  notice  shall
   26  include the clinical rationale, if any, for such determination,
   27    (iii)  be  subject to the terms and conditions generally applicable to
   28  benefits under the evidence of coverage under the health care plan,
   29    (iv) be binding on the plan and the enrollee, and
   30    (v) be admissible in any court proceeding.
   31    S 3. Subparagraph (A) of paragraph 4 of subsection (b) of section 4914
   32  of the insurance law, as added by chapter 586 of the laws  of  1998,  is
   33  amended to read as follows:
   34    (A)  MEDICAL  NECESSITY.  For  external  appeals requested pursuant to
   35  paragraph one of subsection (b) of section four  thousand  nine  hundred
   36  ten  of  this title, the external appeal agent shall review the utiliza-
   37  tion review agent's final adverse determination and, in accordance  with
   38  the  provisions  of this title, shall make a determination as to whether
   39  the health care plan acted reasonably and with  sound  medical  judgment
   40  and  in the best interest of the patient. When the external appeal agent
   41  makes its determination, it shall consider the clinical standards of the
   42  plan, the information provided concerning  the  patient,  the  attending
   43  [physician's]  HEALTH CARE PROFESSIONAL'S recommendation, applicable and
   44  generally accepted practice guidelines developed by the federal  govern-
   45  ment,  national  or professional [medical] societies, boards and associ-
   46  ations. WHERE APPLICABLE, THE APPEAL SHALL BE GRANTED  IF,  AND  TO  THE
   47  EXTENT,  THE EXTERNAL APPEAL AGENT DETERMINES, UPON REVIEW OF THE APPLI-
   48  CABLE MEDICAL AND SCIENTIFIC EVIDENCE, THE PATIENT'S MEDICAL RECORD, AND
   49  ANY OTHER PERTINENT INFORMATION, THAT THE  PROPOSED  HEALTH  SERVICE  OR
   50  TREATMENT IS LIKELY TO BE MORE BENEFICIAL THAN ANY STANDARD TREATMENT OR
   51  TREATMENTS  FOR  THE  PATIENT'S CONDITION OR DISEASE OR NO TREATMENT; IF
   52  THE SPECIFIC HEALTH SERVICE OR TREATMENT RECOMMENDED BY THE HEALTH  CARE
   53  PROFESSIONAL  WOULD  NOT  OTHERWISE  BE EXCLUDED FROM COVERAGE UNDER THE
   54  POLICY ON GROUNDS OTHER  THAN  MEDICAL  NECESSITY.  Provided  that  such
   55  determination shall:
       A. 729                              3
    1    (i)  be conducted only by one or a greater odd number of clinical peer
    2  reviewers,
    3    (ii)  be  accompanied  by a notice of appeal determination which shall
    4  include the reasons for the determination; provided, however, that where
    5  the final adverse determination is upheld on appeal,  the  notice  shall
    6  include the clinical rationale, if any, for such determination,
    7    (iii)  be  subject to the terms and conditions generally applicable to
    8  benefits under the evidence of coverage under the health care plan,
    9    (iv) be binding on the plan and the insured, and
   10    (v) be admissible in any court proceeding.
   11    S 4. This act shall take effect on the one hundred eightieth day after
   12  it shall have become a law.