Directs health maintenance organization which denies claim due to absence of medical necessity to inform insured as to the clinical standards used for the health maintenance organization's determination.
BILL NUMBER: S1509
TITLE OF BILL : An act to amend the insurance law, in relation to notice by health maintenance organizations that a request for coverage of a particular treatment is denied
PURPOSE : This bill would amend the Insurance Law to require health maintenance organizations to furnish an insured client, upon denial of coverage for a requested treatment or procedure, the clinical standards used in that determination.
SUMMARY OF PROVISIONS : Section 1 -- Amends the Insurance Law by adding a new Section 2601-a which directs health maintenance organizations to inform an insured customer of the clinical standards used when denying a medical procedure or treatment.
Section 2 -- Effective date.
JUSTIFICATION : Insured individuals seeking care for a medical condition are sometimes denied coverage for a particular procedure or treatment because it is deemed medically necessary by an insurer. Currently, an insurer is under no obligation to inform the insured about the standards used when denying coverage for a medical treatment or procedure. This bill would direct insurers to inform patients why the requested coverage was denied.
LEGISLATIVE HISTORY : S.4027 of 2007-2008 S.4497 of 2005-2006 S.853 of 2001-2002 S.6504 of 1999-2000
FISCAL IMPLICATIONS : None.
EFFECTIVE DATE : Thirty days after it shall have become a law.
STATE OF NEW YORK ________________________________________________________________________ 1509 2009-2010 Regular Sessions IN SENATE February 2, 2009 ___________Introduced by Sens. DeFRANCISCO, GRIFFO, LARKIN, LAVALLE, MORAHAN, VOLK- ER -- 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 notice by health main- tenance organizations that a request for coverage of a particular treatment is denied THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. The insurance law is amended by adding a new section 2601-a to read as follows: S 2601-A. DENIAL OF COVERAGE OR TREATMENT BY A HEALTH MAINTENANCE ORGANIZATION. WHENEVER A HEALTH MAINTENANCE ORGANIZATION, DOING BUSINESS IN THIS STATE, DENIES A CLAIM FOR COVERAGE OF A PARTICULAR PROCEDURE OR TREATMENT BECAUSE SUCH PROCEDURE OR TREATMENT IS NOT MEDICALLY NECES- SARY, THE HEALTH MAINTENANCE ORGANIZATION SHALL INFORM THE MEMBER AS TO THE CLINICAL STANDARDS USED FOR THE HEALTH MAINTENANCE ORGANIZATION'S DETERMINATION. FOR THE PURPOSES OF THIS SECTION, "CLINICAL STANDARDS" SHALL HAVE THE MEANING ASCRIBED BY SUBSECTION (B-1) OF SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER. S 2. This act shall take effect on the thirtieth day after it shall have become a law.EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD02128-01-9