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 HMOs.
• 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.