BILL NUMBER: S9651
SPONSOR: RIVERA
 
TITLE OF BILL:
An act to amend the public health law and the insurance law, in relation
to utilization review program standards and pre-authorization of health
care services
 
PURPOSE OR GENERAL IDEA OF BILL:
The purpose of this legislation is to reduce administrative burdens on
health care practitioners and patients that interfere with efforts to
assure patients receive appropriate care by amending prior authorization
and utilization review procedures imposed by insurance companies.
 
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 amends paragraph (c) of subdivision 1 of section 4902 of the
public health law, as it relates to utilization review program stand-
ards, by requiring that clinical review criteria utilizes recognized
evidence-based and peer reviewed clinical review criteria while taking
into account the needs of typical patient populations and diagnoses.
Section 2 amends paragraph (a) of subdivision 2 of section 4903 of the
public health law, as it relates to utilization review determinations,
by decreasing the amount of time a utilization review agent would make
and communicate a determination from three business days to seventy-two
hours. This section also requires that if the pre-authorization request
is for a health service related to a medical condition that may place
the insured's health in serious jeopardy, then the determination is to
be made within twenty-four hours of receipt of necessary information.
This section would also require that approval for a pre-authorization
request shall be valid for the duration of care, including prescriptions
with any authorized refills, and the duration of treatment for a specif-
ic condition requested by the enrollee's health care provider.
Section 3 amends paragraph 3 of subsection (a) of section 4902 of the
insurance law, as it relates to utilization review program standards, by
requiring that, for the mandated utilization review plan, clinical
review criteria utilizes recognized evidence-based and peer-reviewed
clinical review criteria that take into account the needs of a typical
patient population and diagnoses.
Section 4 amends paragraph 1 of subsection (b) of section 4903 the
insurance law, as it relates to utilization review determinations, by
decreasing the amount of time a utilization review agent would make and
communicate a determination from three business days to seventy-two
hours. This section also requires that if the pre-authorization request
is for a health service related to a medical condition that may place
the insured's health in serious jeopardy then the determination is to be
made within twenty-four hours of receipt of necessary information.This
section would also require that an approval for a pre-authorization
request would be valid for the duration of care, including prescriptions
with any authorized refills, and the duration of treatment for a specif-
ic condition requested by the enrollee's health care provider.
Section 5 provides the effective date.
 
JUSTIFICATION:
An American Journal of Managed Care 2020 study found that over 90% of
patient care providers experienced delays with prior authorization and
of those delays, 90% had patients who experienced adverse outcomes due
to those delays.
An analysis of prior authorization in the Journal of the American
College of Cardiology, "Using Appropriate Use Criteria to Address Pre-
Authorization," by Robert Shor, MD, FACC notes that health care provid-
ers have developed criteria for utilization management to guide physi-
cians that continue to be subject to prior authorization policies and
denials by plans to ameliorate negative effects on patient care. The
measurable and research-based development criteria is intended to better
a patient's quality of care and outcomes by allowing a solid model to be
in place for health providers to decide whether a specific treatment
would be appropriate and beneficial to the patient.
This bill would recenter patient-care in the health care model and
prioritize better patient outcomes by addressing the potentially harmful
extended timelines of utilization and prior authorization reviews
employed by insurance companies. To help accomplish this, the bill would
remove references in current law to prior authorization timeframes that
rely on "business days," allowing for situations in which a patient may
have their care delayed because of a weekend.
The prior authorization process already creates processing delays and
worsened patient outcomes, and this bill takes corrective action to
minimize the impact on a patient's ability to access the care they need.
Additionally, the bill creates continuity and eliminates duplicative
prior authorizations for prescriptions and a course of treatment to make
it more likely for an individual to continue care and adhere to the
treatment plan ordered by their health care provider without unreason-
able delays by their health insurance plan.
 
PRIOR LEGISLATIVE HISTORY:
2025: S7297A Hoylman-Sigal / A3789-A Weprin
2023-24: S3400-A Breslin / A7268-A Weprin
2021-22: S6435-B Breslin / A7129-A Gottfried
2019-20: S2847 Breslin / A3038 Gottfried
2018: S7872 Hannon / A9588 Gottfried
 
FISCAL IMPLICATIONS:
Undetermined.
 
EFFECTIVE DATE:
180 days after it shall have become a law.

Statutes affected:
S9651: 4902 public health law, 4902(1) public health law, 4902 insurance law, 4902(a) insurance law