What's happening
This bill limits health insurers from denying payment for treatments of symptoms or side effects given alongside pre-authorized care unless specific exceptions are met.
Why it matters
Protects patients from surprise denials. By restricting insurers from refusing to pay for treatments addressing symptoms or side effects given during pre-approved care, the bill helps ensure patients don’t get stuck with unexpected medical bills for necessary support treatments.
Raises the bar for denial. Payment for these additional treatments can only be denied if the insurer proves the treatment is not covered, not medically necessary, experimental, or meets specific pre-existing exceptions—making it harder for insurers to deny claims on procedural grounds alone.
Helps streamline appeals. If a denial is appealed, the insurer must justify the decision based on substantive criteria, potentially reducing the administrative burden on patients and providers fighting for coverage.
Improves continuity of care. By closing this loophole, the bill encourages more seamless and comprehensive treatment, as doctors can address side effects or symptoms in real time without worrying that insurance won’t pay, supporting better health outcomes.
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Who cares
Headline styles
Stop Surprise Treatment Denials
Plain English, a few words. Used as the page title.
Sponsors
No co-sponsors yet.
History
- Recommit, enacting clause stricken
- 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.
Protect Emergency Medical Coverage
Assembly Floor Calendar · Sponsor Pamela J. Hunter
Full text
1 pageUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
1394
2019-2020 Regular Sessions
IN SENATE
January 14, 2019
Introduced by Sen. RIVERA -- 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.
LBD04761-01-9
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 authori- zation.
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 proce- dure, 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, howev- er, 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 contin- ue 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 authori- zation. 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 delay- ing or denying necessary treatment on the sole basis that they were not specifically prior authorized.
Legislative history
2016: S.7558 2017: S.3565
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.