What's happening
This bill shortens the time insurers have to decide if pre-authorization requests for medical services are medically necessary.
Why it matters
Reduces insurer response time. The bill shortens the period insurers have to decide on pre-authorization requests from three "business days" to three "days" (including weekends and holidays), which could lead to faster patient access to needed medical services.
Potentially decreases treatment delays. By requiring quicker determinations, the bill aims to minimize administrative wait times that can delay care—especially important for urgent or time-sensitive treatments.
Could impact insurer operations and provider workflows. Insurers and utilization review agents may need to adjust staffing and systems to handle requests on weekends and holidays, potentially leading to operational changes and increased administrative costs.
Improves transparency for patients. The law maintains requirements for clear, timely communication about coverage status, network participation, and out-of-pocket costs, helping patients and providers make informed decisions sooner.
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Who cares
Headline styles
Speed Up Insurance Decisions
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.
Speed Up Insurance Decisions
In Assembly Committee · Insurance · Sponsor Edward Braunstein
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
2498
2019-2020 Regular Sessions
IN SENATE
January 25, 2019
Introduced by Sen. MARTINEZ -- 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 shortening time frames during which an insurer has to determine whether a pre-authorization request is medically necessary
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Subsection (b) of section 4903 of the insurance law, as amended by chapter 371 of the laws of 2015, is amended to read as follows:
(b) (1) A utilization review agent shall make a utilization review determination involving health care services which require pre-authorization and provide notice of a determination to the insured or insured's designee and the insured's health care provider by telephone and in writing within three [business] days of receipt of the necessary information. To the extent practicable, such written notification to the enrollee's health care provider shall be transmitted electronically, in a manner and in a form agreed upon by the parties. The notification shall identify: (i) whether the services are considered in-network or out-of-network; (ii) whether the insured will be held harmless for the services and not be responsible for any payment, other than any applicable co-payment, co-insurance or deductible; (iii) as applicable, the dollar amount the health care plan will pay if the service is out-ofnetwork; and (iv) as applicable, information explaining how an insured may determine the anticipated out-of-pocket cost for out-of-network health care services in a geographical area or zip code based upon the difference between what the health care plan will reimburse for out-ofnetwork health care services and the usual and customary cost for outof-network health care services.
(2) With regard to individual or group contracts authorized pursuant to article thirty-two, forty-three or forty-seven of this chapter or
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02684-01-9
S. 2498 2
article forty-four of the public health law, for utilization and review determinations involving proposed mental health and/or substance use disorder services where the insured or the insured's designee has, in a format prescribed by the superintendent, certified in the request that the proposed services are for an individual who will be appearing, or has appeared, before a court of competent jurisdiction and may be subject to a court order requiring such services, the utilization review agent shall make a determination and provide notice of such determination to the insured or the insured's designee by telephone within seventy-two hours of receipt of the request. Written notice of the determination to the insured or insured's designee shall follow within three business days. Where feasible, such telephonic and written notice shall also be provided to the court.
§ 2. Subdivision 2 of section 4903 of the public health law, as amended by chapter 371 of the laws of 2015, is amended to read as follows:
2. (a) A utilization review agent shall make a utilization review determination involving health care services which require pre-authorization and provide notice of a determination to the enrollee or enrollee's designee and the enrollee's health care provider by telephone and in writing within three [business] days of receipt of the necessary information. To the extent practicable, such written notification to the enrollee's health care provider shall be transmitted electronically, in a manner and in a form agreed upon by the parties. The notification shall identify; (i) whether the services are considered in-network or out-of-network; (ii) and whether the enrollee will be held harmless for the services and not be responsible for any payment, other than any applicable co-payment or co-insurance; (iii) as applicable, the dollar amount the health care plan will pay if the service is out-of-network; and (iv) as applicable, information explaining how an enrollee may determine the anticipated out-of-pocket cost for out-of-network health care services in a geographical area or zip code based upon the difference between what the health care plan will reimburse for out-of-network health care services and the usual and customary cost for out-of-network health care services.
(b) With regard to individual or group contracts authorized pursuant to article forty-four of this chapter, for utilization review determinations involving proposed mental health and/or substance use disorder services where the enrollee or the enrollee's designee has, in a format prescribed by the superintendent of financial services, certified in the request that the proposed services are for an individual who will be appearing, or has appeared, before a court of competent jurisdiction and may be subject to a court order requiring such services, the utilization review agent shall make a determination and provide notice of such determination to the enrollee or the enrollee's designee by telephone within seventy-two hours of receipt of the request. Written notice of the determination to the enrollee or enrollee's designee shall follow within three business days. Where feasible, such telephonic and written notice shall also be provided to the court.
§ 3. This act shall take effect immediately.
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 and the public health law, in relation to shortening time frames during which an insur- er has to determine whether a pre-authorization request is medically necessary
Purpose
To shorten time frames during which an insurer has to determine whether a pre-authorization request is medically necessary.
Summary of provisions
Section 1. Amends Subsection (b) of section 4903 of the insurance law to require that a utilization review agent shall make a determination involving health care services which require pre-authorization and provide notice of the determination to the insured by telephone and in writing within three days, rather than three business days, of receipt of the necessary information.
Section 1-a. Ensures the above changes are retained in law upon the expiration of the existing subsection (b) on March 31, 2015.
Section 2. Amends subdivision 2 of section 4903 of the public health law to require that a utilization review agent shall make a utilization review determination involving health care services which require pre- authorization and provide notice of a determination to the enrollee by telephone and in writing within three days of receipt of the necessary information.
Section 2-a. Ensures the above changes are retained in law upon the expiration of the existing subdivision 2 on March 31, 2015.
Section 3. Contains the effective date.
Justification
Hospitalized patients must receive pre-authorization from their insur- ance companies in order to have some health care services covered, including the transfer of a patient from a hospital to a nursing home or rehabilitation center. Currently, the timeframe within which insurance companies must issue this determination is three business days. However, this time frame is too long for many patients, particularly over long holiday weekends, where the patient must wait an additional three to four days in the hospital without beginning to recover.
The current time frame prevents many patients from leaving the hospital as they prepare to be transferred to a rehabilitation facility. These rehabilitation facilities are often prepared to accept the patient, but cannot do so without pre-authorization from the insurance company.
Many of these insurance companies already have customer service repre- sentatives available during these days to answer questions from individ- uals or to sign up individuals for coverage. This bill would shorten the timeframe within which approval is required so that hospitalized patients can begin the healing process in a timely manner.
Prior legislative history
2013-2014: A.8442/S.6459 - Referred to Insurance. 2015-2016: A.5129/S.1397-A - Amend and Recommit to Insurance. 2017-2018: A.862 - Referred to Insurance.
Fiscal implications
None.
Effective date
This act shall take effect immediately.
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