Bill Text: NY A03789 | 2025-2026 | General Assembly | Introduced
Bill Title: Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; relates to prescription drug formulary changes and pre-authorization for certain health care services.
Spectrum: Moderate Partisan Bill (Democrat 31-7)
Status: (Introduced) 2025-01-30 - referred to insurance [A03789 Detail]
Download: New_York-2025-A03789-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 3789 2025-2026 Regular Sessions IN ASSEMBLY January 30, 2025 ___________ Introduced by M. of A. WEPRIN, WOERNER, TAYLOR, SANTABARBARA, COLTON, LUPARDO, STIRPE, EPSTEIN, PAULIN, SEAWRIGHT, SIMON, LAVINE, STECK, TANNOUSIS, ROSENTHAL, MEEKS, DAVILA, WILLIAMS, LUNSFORD, BORES, PIROZ- ZOLO, KELLES, R. CARROLL, SIMPSON, BENDETT, REYES, ANGELINO, SAYEGH, LEVENBERG, RAMOS, DiPIETRO, GALLAHAN, RAGA, HEVESI, CLARK, SHRESTHA, CUNNINGHAM, McMAHON -- read once and referred to the Committee on Insurance 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: 1 Section 1. Paragraph (c) of subdivision 1 of section 4902 of the 2 public health law, as added by chapter 705 of the laws of 1996, is 3 amended to read as follows: 4 (c) Utilization of written clinical review criteria developed pursuant 5 to a utilization review plan. Such clinical review criteria shall 6 utilize recognized evidence-based and peer reviewed clinical review 7 criteria that take into account the needs of a typical patient popu- 8 lations and diagnoses; 9 § 2. Paragraph (a) of subdivision 2 of section 4903 of the public 10 health law, as separately amended by section 13 of part YY and section 3 11 of part KKK of chapter 56 of the laws of 2020, is amended to read as 12 follows: 13 (a) A utilization review agent shall make a utilization review deter- 14 mination involving health care services which require pre-authorization 15 and provide notice of a determination to the enrollee or enrollee's 16 designee and the enrollee's health care provider by telephone and in 17 writing within [three business days] seventy-two hours of receipt of the 18 necessary information, within twenty-four hours of the receipt of neces- 19 sary information if the request is for an enrollee with a medical condi- EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD07503-01-5A. 3789 2 1 tion that places the health of the insured in serious jeopardy without 2 the health care services recommended by the enrollee's health care 3 professional, or for inpatient rehabilitation services following an 4 inpatient hospital admission provided by a hospital or skilled nursing 5 facility, within one business day of receipt of the necessary informa- 6 tion. The notification shall identify[;]: (i) whether the services are 7 considered in-network or out-of-network; (ii) and whether the enrollee 8 will be held harmless for the services and not be responsible for any 9 payment, other than any applicable co-payment or co-insurance; (iii) as 10 applicable, the dollar amount the health care plan will pay if the 11 service is out-of-network; and (iv) as applicable, information explain- 12 ing how an enrollee may determine the anticipated out-of-pocket cost for 13 out-of-network health care services in a geographical area or zip code 14 based upon the difference between what the health care plan will reim- 15 burse for out-of-network health care services and the usual and custom- 16 ary cost for out-of-network health care services. An approval for a 17 request for pre-authorization shall be valid for (1) the duration of the 18 prescription, including any authorized refills and (2) the duration of 19 treatment for a specific condition as requested by the enrollee's health 20 care provider. 21 § 3. Paragraph 3 of subsection (a) of section 4902 of the insurance 22 law, as added by chapter 705 of the laws of 1996, is amended to read as 23 follows: 24 (3) Utilization of written clinical review criteria developed pursuant 25 to a utilization review plan. Such clinical review criteria shall 26 utilize recognized evidence-based and peer reviewed clinical review 27 criteria that take into account the needs of a typical patient popu- 28 lations and diagnoses; 29 § 4. Paragraph 1 of subsection (b) of section 4903 of the insurance 30 law, as separately amended by section 16 of part YY and section 7 of 31 part KKK of chapter 56 of the laws of 2020, is amended to read as 32 follows: 33 (1) A utilization review agent shall make a utilization review deter- 34 mination involving health care services which require pre-authorization 35 and provide notice of a determination to the insured or insured's desig- 36 nee and the insured's health care provider by telephone and in writing 37 within [three business days] seventy-two hours of receipt of the neces- 38 sary information, within twenty-four hours of receipt of necessary 39 information if the request is for an insured with a medical condition 40 that places the health of the insured in serious jeopardy without the 41 health care services recommended by the insured's health care provider, 42 or for inpatient rehabilitation services following an inpatient hospital 43 admission provided by a hospital or skilled nursing facility, within one 44 business day of receipt of the necessary information. The notification 45 shall identify: (i) whether the services are considered in-network or 46 out-of-network; (ii) whether the insured will be held harmless for the 47 services and not be responsible for any payment, other than any applica- 48 ble co-payment, co-insurance or deductible; (iii) as applicable, the 49 dollar amount the health care plan will pay if the service is out-of- 50 network; and (iv) as applicable, information explaining how an insured 51 may determine the anticipated out-of-pocket cost for out-of-network 52 health care services in a geographical area or zip code based upon the 53 difference between what the health care plan will reimburse for out-of- 54 network health care services and the usual and customary cost for out- 55 of-network health care services. An approval of request for pre-authori- 56 zation shall be valid for (1) the duration of the prescription,A. 3789 3 1 including any authorized refills and (2) the duration of treatment for a 2 specific condition requested for pre-authorization. 3 § 5. This act shall take effect on the one hundred eightieth day after 4 it shall have become a law.
