Requires specification between partial approval of medical claims or payments and full denial of medical claims or payments on written notices to an insurer or an organization or corporation licensed or certified.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A1677A
SPONSOR: Gottfried PURPOSE:
The purpose of this legislation is to provide individuals with accurate
medical insurance coverage snotices
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 amends subsection (b) of Section 3224-A of the Insurance law
by requiring medical insurance notices to conspicuously state whether a
claim or a bill has been partially approved or entirely denied.
Section 2 is the effective date.
JUSTIFICATION:
Medical insurance companies send individuals letters that conspicuously
state that their medical coverage for a procedure or therapy has been
denied; however, when looking closer at the notice, the coverage is
actually, partially approved. This legislation aims to end this decep-
tive practice and to require medical insurance companies to provide
coverage letters with accurate coverage information. This bill is part
of the effort to make New York's insurance companies more accountable to
the people they serve. These hugely profitable companies must provide
their customers with clear, understandable, and unambiguous statements
so customers can know what has been accepted and what has been rejected
regarding their services. We must begin a new era of transparency that
benefits the consumer.
PRIOR LEGISLATIVE HISTORY:
2020: A9085 Referred to Insurance Committee
STATE AND LOCAL FISCAL IMPLICATIONS:
None.
EFFECTIVE DATE: :
This act shall take effect on the 90th day after it shall have become a
law and shall apply to policies and contracts issued, renewed, modified,
altered or amended on or after such effective date.
STATE OF NEW YORK
________________________________________________________________________
1677--A
2021-2022 Regular Sessions
IN ASSEMBLY
January 11, 2021
___________
Introduced by M. of A. GOTTFRIED -- read once and referred 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 requiring specifica-
tion between partial approval of medical claims and a denial of
medical claims on written notices to an insurer
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subsection (b) of section 3224-a of the insurance law, as
2 amended by section 8 of part YY of chapter 56 of the laws of 2020, is
3 amended to read as follows:
4 (b) In a case where the obligation of an insurer or an organization or
5 corporation licensed or certified pursuant to article forty-three or
6 forty-seven of this chapter or article forty-four of the public health
7 law to pay a claim or make a payment for health care services rendered
8 is not reasonably clear due to a good faith dispute regarding the eligi-
9 bility of a person for coverage, the liability of another insurer or
10 corporation or organization for all or part of the claim, the amount of
11 the claim, the benefits covered under a contract or agreement, or the
12 manner in which services were accessed or provided, an insurer or organ-
13 ization or corporation shall pay any undisputed portion of the claim in
14 accordance with this subsection and notify the policyholder, covered
15 person or health care provider in writing, and through the internet or
16 other electronic means for claims submitted in that manner, within thir-
17 ty calendar days of the receipt of the claim:
18 (1) whether the claim or bill has been denied or partially approved;
19 (2) which claim or medical payment that it is not obligated to pay
20 [the claim or make the medical payment,] stating the specific reasons
21 why it is not liable; [or
22 (2)] and
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD00505-04-1
A. 1677--A 2
1 (3) to request all additional information needed to determine liabil-
2 ity to pay the claim or make the health care payment; and
3 [(3)] (4) of the specific type of plan or product the policyholder or
4 covered person is enrolled in; provided that nothing in this section
5 shall authorize discrimination based on the source of payment.
6 Upon receipt of the information requested in paragraph [two] three of
7 this subsection or an appeal of a claim or bill for health care services
8 denied pursuant to [paragraph one of] this subsection, an insurer or
9 organization or corporation licensed or certified pursuant to article
10 forty-three or forty-seven of this chapter or article forty-four of the
11 public health law shall comply with subsection (a) of this section;
12 provided, that if the insurer or organization or corporation licensed or
13 certified pursuant to article forty-three or forty-seven of this chapter
14 or article forty-four of the public health law determines that payment
15 or additional payment is due on the claim, such payment shall be made to
16 the policyholder or covered person or health care provider within
17 fifteen days of the determination. Any denial or partial approval of
18 claim or payment and the specific reasons for such denial or partial
19 approval pursuant to this subsection shall be prominently displayed on a
20 written notice with at least twelve-point type. A partial approval of
21 claim or payment shall state at the top of such written notice with at
22 least fourteen-point type bold: "NOTICE OF PARTIAL APPROVAL OF MEDICAL
23 COVERAGE". A denial of claim or payment shall state at the top of such
24 written notice with at least fourteen-point type bold: "NOTICE OF DENIAL
25 OF MEDICAL COVERAGE". Any additional terms or conditions included on
26 such notice of partial approval or such notice of denial, such as but
27 not limited to time restraints to file an appeal, shall be included with
28 at least twelve-point type.
29 § 2. This act shall take effect on the ninetieth day after it shall
30 have become a law and shall apply to policies and contracts issued,
31 renewed, modified, altered or amended on or after such effective date.
