What's happening
This bill ensures that insurance cannot deny payment for medically necessary additional procedures done without pre-authorization during treatment, unless specific exceptions apply.
Why it matters
Protects patients and providers when urgent, unforeseen medical needs arise. If a doctor determines during treatment that another procedure is immediately necessary (for example, to address a co-morbid condition), insurance cannot deny payment solely because there was no pre-authorization—unless the new procedure is not covered, not medically necessary, or is experimental.
Reduces administrative delays and disruptions in care. The bill aims to prevent situations where a provider must halt treatment to seek insurance approval for an additional procedure, which can be harmful or impractical for the patient.
Limits insurer discretion to deny claims for technicalities. Insurers can only deny payment for these additional procedures in specific cases, such as lack of coverage, lack of medical necessity, or if the procedure is experimental, closing a loophole that allowed denials based on differing billing codes.
Applies even when billing codes differ. The protections apply regardless of whether the additional procedure has a different CPT (billing) code than the original, ensuring broader protection for both providers and patients against claim denials due to code discrepancies.
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Who cares
Headline styles
Protect Patients' Coverage Rights
Plain English, a few words. Used as the page title.
Sponsors
1 Co-sponsor
History
- Signed chap.640
- Delivered to governor
- Returned to senate
- Passed assembly
- Ordered to third reading cal.493
- Substituted for A2880B
- Referred to codes
- Delivered to assembly
- Passed senateVote 62–0
- Ordered to third reading cal.1509
- Committee discharged and committed to rules
- Print number 5328a
Show 2 earlier actions
- Amend (t) and recommit 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.
Protect Emergency Medical Coverage
Assembly Floor Calendar · Sponsor Pamela J. Hunter
Full text
2 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
5328--A
2019-2020 Regular Sessions
IN SENATE
April 26, 2019
Introduced by Sen. BRESLIN -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee
AN ACT to amend the insurance law, in relation to denial of coverage of additional or related services or procedures related to health care services for which pre-authorization was granted or did not require pre-authorization; and to repeal certain provisions of such law relating thereto
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Subsection (c) of section 3238 of the insurance law is REPEALED and a new subsection (c) is added to read as follows:
(c)(1) If a health care provider, while providing a service or procedure to treat a patient, determines that providing an additional or related service or procedure, such as a service or procedure to address a co-morbid condition, is immediately necessary as part of such treatment, and in the clinical judgment of the health care provider it is a medically timely service and it would not be medically advisable to interrupt the provision of care to the patient in order to obtain preauthorization from a health plan for the additional or related service or procedure, a denial of payment for the additional or related service or procedure due to lack of pre-authorization shall be upheld on appeal only if it is determined that:
(i) the additional or related service or procedure is not a covered benefit;
(ii) the additional or related service or procedure 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;
(iii) the additional or related service or procedure was experimental or investigational pursuant to section four thousand nine hundred four
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD04761-06-9
S. 5328--A 2
of this chapter or section forty-nine hundred four of the public health law; or
(iv) one of the conditions set forth in paragraphs one through six of subsection (a) of this section is met.
(2) The provisions of this subsection shall apply to situations in which pre-authorization was required and received for the initial service or procedure.
(3) The provisions of this subsection shall apply without regard to whether the current procedural terminology (CPT) code for the additional or related service or procedure is different than the CPT code for the initial service or procedure.
§ 2. 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 insurance law, in relation to denial of coverage of additional or related services or procedures related to health care services for which pre-authorization was granted or did not require pre-authorization; and to repeal certain provisions of such law relating thereto
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 the delaying or denying necessary treatment on the sole basis that they were not specifically prior authorized.
Legislative history
New Bill.
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.