S5472 (Breslin)/A8402 (Morelle)
Managed Care; Consumer and Provider Protections
Summary: The bill amends the Insurance Law and the Public Heath Law to institute a series of managed
care reforms designed to enhance the protection of consumers and providers by:
- Requiring that a provider be given notice of an adverse reimbursement change to a provider contract
and an opportunity to cancel the contract.
- Requiring insurers that offer comprehensive policies
to offer the same grievance procedures and provide the same access to care that is required for
- Requiring insurers and HMOs to pay electronic claims promptly and limiting their ability
to respond to claims by sending a COB questionnaire.
- Extending overpayment recovery protections
to all health care providers and permitting them to challenge such recoveries.
- Requiring insurers
and HMOs that fail to meet loss ratio requirements to make efforts to locate and pay dividends
or credits to former policy holders.
- Prohibiting health plans from treating a participating provider
as a non-participating provider.
- Requiring insurers to have an adequate provider network.
- Permitting newly licensed providers and
providers moving to New York to be provisionally credentialed until the final credentialing decision
is made by the health plan.
- Shortening utilization review timeframes for determinations involving
post-hospital health care services.
- Requiring that services be approved if a utilization
review agent fails to meet a utilization review timeframe.
- Allowing providers to appeal concurrent
adverse determinations through the external appeal process.
- Establishing a new external appeal
standard for rare disease treatments
- Authorizing the Superintendent
to require that mandated submissions be filed electronically.
Effective Date: Credentialing provisions October 1, 2009. Otherwise, January 1, 2010.