Relates to utilization review determinations

Showing the cosponsors who are on Agora, A to Z. The official record may list more.

• Democratic28

Shown in neutral colors by design; Agora is non-partisan.

◆ The sponsor's argument

Why Nathalia Fernandez says this is needed

When utilization review agents make medical necessity determinations that are inconsistent with medical and scientific evidence, enrollees are frequently unable to access critically needed services, including for mental health and substance use disorders. In New York, health plans must already determine the appropriate level of care for substance use disorders using a single tool, LOCADTR, which was developed by the Office of Addiction Services and Supports. Howev- er, there is no such requirement for other mental health conditions. Instead, inconsistent, opaque, and non-validated clinical review crite- ria are frequently used, hindering system-wide efforts to align around a single set of high-quality criteria to improve health care quality and access. Additionally, providers have experienced aggressive post-service audits by health plans that claw back significant payments for previously approved care. Such practices have driven mental health and substance use disorder providers out of insurer networks, leaving enrollees unable to find in-network care. The legislation amends New York's Insurance and Public Health laws to increase access to appropriate care by requiring health insurers to make medical necessity determinations consistent with medical and scientific evidence, using transparent clinical review criteria. For mental health conditions, it allows the Office of Mental Health to designate specific level of care criteria. Further, the legislation prohibits insurers from reversing or altering a determination of medical necessity previously made by the utilization review agent, except in cases of fraud. Legislation requiring health plans to use fair standards for coverage determinations will increase access to medically necessary services as promised in plan policies, preventing inappropriate denials of needed mental health and substance use disorder care.

This is the sponsor's own case for the bill, quoted from their memorandum. It is not Agora's description of what the bill does.