What's happening
This bill requires insurance utilization review agents to follow specific timelines for reviewing and covering nursing home care after hospital discharge.
Why it matters
Reduces the risk of care delays for patients. By imposing strict timelines for insurance companies to decide on nursing home care coverage after a hospital stay, the bill helps ensure that patients aren’t left waiting for critical post-hospitalization care due to insurance processing delays.
Limits insurance denial while decisions are pending. If a request for nursing home care is submitted at least 24 hours before hospital discharge, insurers cannot deny coverage for medical necessity or lack of prior authorization while their review is ongoing—protecting patients from sudden gaps in care.
Improves hospital discharge planning and patient flow. Hospitals can more effectively plan discharges knowing that insurance reviews for nursing home care must be completed quickly, which can reduce unnecessary hospital stays and open up beds for other patients.
Aligns nursing home care with other urgent post-hospital needs. The bill places nursing home care reviews on par with substance use disorder and home health care reviews, recognizing the urgency and importance of timely transitions for vulnerable populations.
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Who cares
Headline styles
Speed Up Nursing Home Reviews
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Committed to rules
- Vote reconsidered - restored to third reading
- Substitution reconsidered
- Substituted by A7108
- Advanced to third reading
- 2nd report cal.
- 1st report cal.982
- Referred to health
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.
Faster Nursing Home Review
In Senate Committee · Rules · Sponsor Richard Gottfried
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
7871
IN SENATE
March 5, 2018
Introduced by Sen. HANNON -- read twice and ordered printed, and when printed to be committed to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation to utilization review of coverage of nursing home care following an inpatient hospital admission
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Paragraphs (a) and (c) of subdivision 3 of section 4903 of the public health law, paragraph (a) as amended and paragraph (c) as added by chapter 41 of the laws of 2014, are amended to read as follows:
(a) A utilization review agent shall make a determination involving continued or extended health care services, additional services for an enrollee undergoing a course of continued treatment prescribed by a health care provider, or requests for inpatient substance use disorder treatment, or nursing home care or home health care services following an inpatient hospital admission, and shall provide notice of such determination to the enrollee or the enrollee's designee, which may be satisfied by notice to the enrollee's health care provider, by telephone and in writing within one business day of receipt of the necessary information except, with respect to home health care services following an inpatient hospital admission, within seventy-two hours of receipt of the necessary information when the day subsequent to the request falls on a weekend or holiday and except, with respect to inpatient substance use disorder treatment or nursing home care, within twenty-four hours of receipt of the request for services when the request is submitted at least twenty-four hours prior to discharge from an inpatient admission. Notification of continued or extended services shall include the number of extended services approved, the new total of approved services, the date of onset of services and the next review date.
(c) Provided that a request for inpatient treatment for substance use disorder or nursing home care is submitted to the utilization review agent at least twenty-four hours prior to discharge from an inpatient admission pursuant to this subdivision, a utilization review agent shall not deny, on the basis of medical necessity or lack of prior authori-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02606-01-7
S. 7871 2
zation, coverage for the inpatient substance use disorder treatment or nursing home care while a determination by the utilization review agent is pending.
§ 2. Paragraphs 1 and 3 of subsection (c) of section 4903 of the insurance law, paragraph 1 as amended and paragraph 3 as added by chapter 41 of the laws of 2014, are amended to read as follows:
(1) A utilization review agent shall make a determination involving continued or extended health care services, additional services for an insured undergoing a course of continued treatment prescribed by a health care provider, or requests for inpatient substance use disorder treatment, or nursing home care or home health care services following an inpatient hospital admission, and shall provide notice of such determination to the insured or the insured's designee, which may be satisfied by notice to the insured's health care provider, by telephone and in writing within one business day of receipt of the necessary information except, with respect to home health care services following an inpatient hospital admission, within seventy-two hours of receipt of the necessary information when the day subsequent to the request falls on a weekend or holiday and except, with respect to inpatient substance use disorder treatment or nursing home care, within twenty-four hours of receipt of the request for services when the request is submitted at least twenty-four hours prior to discharge from an inpatient admission. Notification of continued or extended services shall include the number of extended services approved, the new total of approved services, the date of onset of services and the next review date.
(3) Provided that a request for inpatient treatment for substance use disorder or nursing home care is submitted to the utilization review agent at least twenty-four hours prior to discharge from an inpatient admission pursuant to this subsection, a utilization review agent shall not deny, on the basis of medical necessity or lack of prior authorization, coverage for the inpatient substance use disorder treatment or nursing home care while a determination by the utilization review agent is pending.
§ 3. This act shall take effect on the ninetieth day after it shall have become a law.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the public health law and the insur- ance law, in relation to utilization review of coverage of nursing home care following an inpatient hospital admission
Purpose
To decrease delays for post-acute care by adding nursing home care to the types of care for which an insurer must make a determination on authorization within twenty-four hours.
Summary of provisions
Section one amends paragraphs (a) and (c) of subdivision 3 of section 4903 of the Public Health Law by requiring that health care plans make a determination involving continued or extended post acute nursing home care within twenty four hours of receipt of request for services and by prohibiting denial of nursing home coverage on the basis of medical necessity or lack of prior authorization while the determination is pending.
Section two makes the aforementioned amendments to paragraphs 1 and 3 of subsection (c) of section 4903 of the Insurance Law.
Section three provides that this act shall take effect 90 days after enactment.
Justification
Many patients require home care or skilled nursing home care upon discharge from the hospital. Hospitals increasingly experience delays in obtaining authorizations from insurers for post-acute care. Since most insurers pay hospitals based on diagnosis-related group systems, it does not cost the insurer any more to have patients stay in the hospital for a few extra days and doing so can reduce insurer costs for post-acute care. This is not good for patients, nor is it good for hospitals trying to operate as efficiently as possible.
State law has been modified twice in recent years to tighten timeframes for authorization for post-acute home care and substance abuse services. This legislation will extend the tightened timeframe to skilled nursing home services, requiring insurers to make determinations on requests for nursing home care following an inpatient admission within 24 hours of receipt of a request as long as the request is made at least 24 hours prior to discharge from the hospital. This change is particularly impor- tant now that the Medicaid nursing home benefit has moved from Medicaid fee-for-service to managed care.
Legislative history
S.6492 of 2016
Fiscal implications
None
Effective date
90 days after enactment
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.