What's happening
This bill requires health maintenance organizations to explain coverage denials by identifying covered alternatives or citing past ineffectiveness.
Why it matters
Improves transparency. for patients by requiring health maintenance organizations (HMOs) to clearly explain why a treatment was denied, reducing confusion over insurance decisions.
Helps patients make informed choices. by mandating that HMOs identify covered alternative treatments when denying coverage for a specific procedure, potentially speeding up access to effective care.
Limits arbitrary denials. by obligating insurers to justify denials based on past ineffectiveness if no alternatives are provided, encouraging HMOs to base decisions on evidence rather than cost-cutting alone.
Empowers patients in appeals. by providing them with specific reasons for denial, which can strengthen their case if they choose to challenge the insurer’s decision.
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History
- Referred to insurance
- Referred to insurance
Full text
1 pageUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
766
2017-2018 Regular Sessions
IN ASSEMBLY
January 9, 2017
Introduced by M. of A. PRETLOW -- read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to notice by health maintenance organizations that a request for coverage of a particular treatment is denied
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. The insurance law is amended by adding a new section 2601-a to read as follows:
§ 2601-a. Denial of coverage or treatment by a health maintenance organization. Whenever a health maintenance organization, doing business in this state, denies a claim for coverage of a particular procedure or treatment because such procedure or treatment is not medically necessary, the health maintenance organization shall inform the insured as to those preferred procedure or treatment options which would be covered, or provide the insured with a statement as to the past ineffectiveness of the requested procedure or treatment.
§ 2. This act shall take effect on the thirtieth day after it shall have become a law.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD05158-01-7
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.