Bill Text: NY S02680 | 2023-2024 | General Assembly | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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

Spectrum: Moderate Partisan Bill (Democrat 6-1)

Status: (Introduced - Dead) 2024-01-22 - PRINT NUMBER 2680A [S02680 Detail]

Download: New_York-2023-S02680-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          2680

                               2023-2024 Regular Sessions

                    IN SENATE

                                    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:

     1    Section 1. Subsection (a) of section 4902  of  the  insurance  law  is
     2  amended by  adding a new paragraph 14 to read as follows:
     3    (14)  Establishment of an exemption from preauthorization requirements
     4  for health care professionals providing health care services which shall
     5  include that:
     6    (i) an insurer that uses a preauthorization process  for  health  care
     7  services  shall  not require a health care professional to obtain preau-
     8  thorization for a particular health care service if, in the most  recent
     9  six-month  evaluation  period,  the  insurer  has approved not less than
    10  ninety percent of the preauthorization requests submitted by such health
    11  care professional for the particular health care service;
    12    (ii) the insurer shall evaluate whether  a  health  care  professional
    13  qualifies  for  an  exemption  from  preauthorization requirements under
    14  subparagraph (i) of this paragraph once every six months;
    15    (iii) the insurer may continue an exemption under subparagraph (i)  of
    16  this  paragraph  without evaluating whether the health care professional
    17  qualifies for the exemption for a particular evaluation period;
    18    (iv) a health care professional shall not be required  to  request  an
    19  exemption to qualify for the exemption;
    20    (v)  a  health  care  professional's  exemption  from preauthorization
    21  requirements under subparagraph (i) of this paragraph  shall  remain  in
    22  effect until:
    23    (A)  the  thirtieth day after the date the insurer notifies the health
    24  care professional  of  the    insurer's  determination  to  rescind  the
    25  exemption pursuant to subparagraph (vii) of this paragraph if the health
    26  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

     1    (B)  where  the health care professional appeals the determination and
     2  the independent review organization affirms the insurer's  determination
     3  to  rescind  the  exemption, the fifth day after the affirmation of such
     4  determination;
     5    (vi)  where an insurer does not finalize a rescission determination as
     6  specified in subparagraph (vii)  of  this  paragraph,  the  health  care
     7  professional shall be considered to have met the criteria to continue to
     8  qualify  for  the  exemption  and  such exemption shall remain in effect
     9  until the following evaluation period;
    10    (vii) an  insurer  may  rescind  an  exemption  from  preauthorization
    11  requirements under subparagraph (i) of this paragraph only:
    12    (A) during January or June of each year; and
    13    (B) the insurer makes a determination, on the basis of a retrospective
    14  review of a random sample of not fewer than five and no more than twenty
    15  claims  submitted by the health care professional during the most recent
    16  evaluation period that less than ninety percent of the  claims  for  the
    17  particular  health  care service met the medical necessity criteria that
    18  would have been used by the   insurer when  conducting  preauthorization
    19  review for the particular health care service during the relevant evalu-
    20  ation period; and
    21    (C)  the  insurer  complies  with all other applicable requirements of
    22  this paragraph and the insurer notifies the health care professional not
    23  less than twenty days before the proposed rescission is to take  effect,
    24  together with the sample of claims used to make the determination pursu-
    25  ant  to clause (B) of this subparagraph and a plain language explanation
    26  of the health care professional's right to appeal such determination and
    27  instructions on how to initiate such appeal;
    28    (viii) notwithstanding any contrary provision of subparagraph  (i)  of
    29  this  paragraph,  an insurer may deny an exemption from preauthorization
    30  requirements:
    31    (A) if the health care professional does not have the exemption at the
    32  time of the relevant evaluation period; and
    33    (B) the insurer provides the  health  care  professional  with  actual
    34  statistics and data for the relevant preauthorization request evaluation
    35  period  and  detailed  information  sufficient  to  demonstrate that the
    36  health care professional does not meet the  criteria  for  an  exemption
    37  pursuant to subparagraph (i) of this paragraph for the particular health
    38  care service;
    39    (ix) after a final determination or review affirming the rescission or
    40  denial  of  an  exemption  for a specific health care service under this
    41  paragraph, a health care professional shall be  eligible  for  consider-
    42  ation  of an exemption for the same health care service after the evalu-
    43  ation period following the evaluation period which formed the  basis  of
    44  the rescission or denial of an exemption;
    45    (x)  the  insurer shall, not later than five days after qualifying for
    46  an exemption pursuant to subparagraph (i) of this paragraph, provide  to
    47  a health care professional a notice that shall include:
    48    (A)  a  statement  that  the health care professional qualifies for an
    49  exemption pursuant to this paragraph;
    50    (B) a description of the health care services to which such  exemption
    51  applies; and
    52    (C)  a  statement  of the duration that such exemption shall remain in
    53  effect; and
    54    (xi) in the event that the health care professional submits  a  preau-
    55  thorization  request for a health care service for which the health care
    56  professional qualifies for an exemption from  preauthorization  require-
        S. 2680                             3

     1  ments  under  subparagraph  (i)  of  this paragraph,   the insurer shall
     2  promptly notify such health care  professional  that  such  health  care
     3  professional has qualified for an exemption for such health care service
     4  in  accordance  with  the requirements of subparagraph (x) of this para-
     5  graph.
     6    (xii) Nothing in this paragraph may be construed to: (A)  authorize  a
     7  health  care  professional  to provide a health care service outside the
     8  scope of such health care  professional's  applicable  license;  or  (B)
     9  prohibit  a health insurer from performing a retrospective review of the
    10  health care service pursuant to section forty-nine hundred three of this
    11  title.
    12    § 2. Subdivision 1 of section 4902 of the public health law is amended
    13  by adding a new paragraph (l) to read as follows:
    14    (l) Establishment of an exemption from  preauthorization  requirements
    15  for  health  care  professionals  providing certain health care services
    16  which shall include that:
    17    (i) a health care plan that uses a preauthorization process for health
    18  care services shall not require a health  care  professional  to  obtain
    19  preauthorization  for  a  particular health care service if, in the most
    20  recent six-month evaluation period, the health care  plan  has  approved
    21  not  less than ninety percent of the preauthorization requests submitted
    22  by such health care professional for the particular health care service;
    23    (ii) such health care  plan  shall  evaluate  whether  a  health  care
    24  professional  qualifies  for an exemption from preauthorization require-
    25  ments under subparagraph (i) of this paragraph once every six months;
    26    (iii) the health care plan may continue an  exemption  under  subpara-
    27  graph  (i)  of this paragraph without evaluating whether the health care
    28  professional qualifies for the exemption  for  a  particular  evaluation
    29  period;
    30    (iv)  a  health  care professional shall not be required to request an
    31  exemption to qualify for the exemption under this paragraph;
    32    (v) a  health  care  professional's  exemption  from  preauthorization
    33  requirements  under  subparagraph  (i) of this paragraph shall remain in
    34  effect until:
    35    (A) the thirtieth day after the date the health care plan notifies the
    36  health care professional of the   health care  plan's  determination  to
    37  rescind  the  exemption pursuant to subparagraph (vii) of this paragraph
    38  if the health care professional does not appeal such determination; or
    39    (B) where the health care professional appeals the  determination  and
    40  the  independent  review  organization  affirms  the  health care plan's
    41  determination to rescind the exemption, the fifth day after the affirma-
    42  tion of such determination;
    43    (vi) where a health care plan does not finalize a rescission  determi-
    44  nation  as specified in subparagraph (vii) of this paragraph, the health
    45  care professional shall be  considered  to  have  met  the  criteria  to
    46  continue to qualify for the exemption and such exemption shall remain in
    47  effect until the following evaluation period;
    48    (vii)  a  health  care  plan may rescind an exemption from preauthori-
    49  zation requirements under subparagraph (i) of this paragraph only:
    50    (A) during January or June of each year; and
    51    (B) the health care plan makes a determination,  on  the  basis  of  a
    52  retrospective  review  of  a random sample of not fewer than five and no
    53  more than twenty claims submitted by the health care professional during
    54  the most recent evaluation period that less than ninety percent  of  the
    55  claims  for the particular health care service met the medical necessity
    56  criteria that would have been  used  by  the    health  care  plan  when
        S. 2680                             4

     1  conducting  preauthorization  review  for  the  particular  health  care
     2  service during the relevant evaluation period; and
     3    (C)  the  health care plan complies with all other applicable require-
     4  ments of this paragraph and the health care  plan  notifies  the  health
     5  care  professional not less than twenty days before the proposed rescis-
     6  sion is to take effect, together with the sample of claims used to  make
     7  the  determination  pursuant  to  clause  (B) of this subparagraph and a
     8  plain language explanation of the health care  professional's  right  to
     9  appeal  such  determination  and  instructions  on  how to initiate such
    10  appeal;
    11    (viii) notwithstanding any contrary provision of subparagraph  (i)  of
    12  this paragraph, a health care plan may deny an exemption from preauthor-
    13  ization requirements:
    14    (A) if the health care professional does not have the exemption at the
    15  time of the relevant evaluation period; and
    16    (B)  the  health  care plan provides the health care professional with
    17  actual statistics and data for  the  relevant  preauthorization  request
    18  evaluation  period  and  detailed  information sufficient to demonstrate
    19  that the health care professional does not  meet  the  criteria  for  an
    20  exemption pursuant to subparagraph (i) of this paragraph for the partic-
    21  ular health care service;
    22    (ix) after a final determination or review affirming the rescission or
    23  denial  of  an  exemption  for a specific health care service under this
    24  paragraph, a health care professional shall be  eligible  for  consider-
    25  ation  of an exemption for the same health care service after the evalu-
    26  ation period following the evaluation period which formed the  basis  of
    27  the rescission or denial of an exemption;
    28    (x)  the health care plan shall, not later than five days after quali-
    29  fying for an exemption pursuant to subparagraph (i) of  this  paragraph,
    30  provide to a health care professional a notice that shall include:
    31    (A)  a  statement  that  the health care professional qualifies for an
    32  exemption pursuant to this paragraph;
    33    (B) a description of the health care services to which such  exemption
    34  applies; and
    35    (C)  a  statement  of the duration that such exemption shall remain in
    36  effect; and
    37    (xi) in the event that the health care professional submits  a  preau-
    38  thorization  request for a health care service for which the health care
    39  professional qualifies for an exemption from  preauthorization  require-
    40  ments  under  subparagraph  (i) of this paragraph,  the health care plan
    41  shall promptly notify such health care  professional  that  such  health
    42  care  professional  has  qualified for an exemption for such health care
    43  service in accordance with the requirements of subparagraph (x) of  this
    44  paragraph.
    45    (xii) Nothing in this paragraph shall be construed to: (A) authorize a
    46  health  care  professional  to provide a health care service outside the
    47  scope of such health care professional's applicable  license;    or  (B)
    48  prohibit  a  health  care plan from performing a retrospective review of
    49  the health care service pursuant to section forty-nine hundred three  of
    50  this title.
    51    § 3. This act shall take effect on the one hundred eightieth day after
    52  it shall have become a law.