What's happening
This bill limits health insurance denials of payment for concurrent treatments without pre-authorization if related care was already pre-authorized, unless specific conditions apply.
Why it matters
Reduces surprise denials for related care. By restricting insurers from denying coverage for treatments given alongside pre-authorized care unless specific exceptions are met, the bill helps patients avoid unexpected medical bills for related, necessary treatments.
Strengthens patient protections during appeals. The burden shifts to insurers to justify denials on specific grounds (such as lack of coverage, medical necessity, or experimental status), giving patients a clearer path to challenge and potentially overturn claim denials.
Limits insurer discretion and administrative hurdles. Health plans can no longer simply deny concurrent treatments for lack of pre-authorization if the main service was already approved, unless they can point to a concrete, policy-based reason, which may streamline care and reduce administrative back-and-forth for both providers and patients.
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Who cares
Headline styles
Stop Coverage Denial After Approval
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Referred to insurance
- Referred to insurance
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Stop Surprise Health Coverage Denials
In Senate Committee · Insurance · Sponsor Pamela J. Hunter
Full text
1 pageUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
3568
2017-2018 Regular Sessions
IN SENATE
January 24, 2017
Introduced by Sen. HANNON -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law, in relation to denial of coverage of treatment related to health care services for which pre-authorization was granted
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Section 3238 of the insurance law is amended by adding a new subsection (c-1) to read as follows:
(c-1) If a health plan denies payment for the treatment of concurrent symptoms or side effects due to lack of pre-authorization and such treatment is rendered at the same time as a health care service for which pre-authorization was required and received, upon the appeal of the denial, the denial of any such service shall be upheld only if it is determined that:
(1) the treatment is not a covered benefit;
(2) the treatment was not medically necessary pursuant to section four thousand nine hundred four of this chapter or section forty-nine hundred four of the public health law;
(3) the treatment was experimental or investigational pursuant to section four thousand nine hundred four of this chapter or section forty-nine hundred four of the public health law; or
(4) one of the conditions set forth in paragraphs one through six of subsection (a) of this section is met.
§ 2. This act shall take effect on the ninetieth day after it shall have become a law.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02613-01-7
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the insurance law, in relation to denial of coverage of treatment related to health care services for which pre-authorization was granted
Purpose
To expand the current prior authorization exception for surgical and invasive procedures to include concurrent symptoms and side effects.
Summary of provisions
Section 1 of the bill adds a new subsection (c-1) of section 3238 of the Insurance Law to include concurrent symptoms and side effects to the types of conditions that cannot be denied for lack of prior authorization.
Section two provides that this act shall take effect 90 days after enactment.
Justification
In 2007, Chapter 451 was signed into law and required plans to reimburse providers when the plan had already provided prior authorization for the care. Importantly, this law also limits when a plan is entitled to deny payment for surgical or invasive procedures that are closely related and rendered at the same time as the services that had been explicitly prior authorized. This flexibility was added to ensure that when a provider encountered an unexpected complication or need during a surgical procedure, it was not medically prudent to leave an individuals' health need unaddressed during the time it took for the health plan to be contacted and issue a separate prior authorization. The law still reserves the plan's right to make a medical necessity determination and simply bars from the plan from issuing an administrative denial over the deviation from the initial authorization.
Recently, certain vendor organizations subcontracted by health plans regulated by New York have been denying related services when they are not clearly pre-authorized although services do not meet the current definition of "surgical or invasive, requiring sedation". These carve- out entities are denying reimbursement for medically sensitive services, even when medically necessary, if not explicitly prior authorized. For example, chemotherapy is prior authorized on an outpatient basis, however, patients who arrive for chemotherapy are often treated for related symptoms such as nausea, low platelet count, allergic reactions, etc. These symptoms are treated by the provider so the individual can continue to receive chemotherapy, especially because patients are maintaining strict regimens to fight their particular type of cancer and/or have traveled long distances to a hospital that provides oncology services.
Similar to the surgical/invasive procedure exception that was initially inserted to the prior authorization law, it is not in the patient's medical interest to leave symptoms unaddressed or delay chemotherapy so the health plan can be contacted to issue a separate prior authorization. This bill would expand this current exception to ensure patients receive medically necessary services when they are in a medically compromised state and prevent plans or their subcontractors from delaying or denying necessary treatment on the sole basis that they were not specifically prior authorized.
Legislative history
2016: S.7558 FISCAL IMPLICATIONS :
None
Effective date
Ninety days after it shall become law.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.