New York S 9651: Relates to utilization review program standards and pre-authorization for certain health care services

Bill Text

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S09651 Summary:

BILL NOS09651 

&nbsp

SAME ASSAME AS A03789

&nbsp

SPONSORRIVERA

&nbsp

COSPNSRADDABBO, BASKIN, CLEARE, GALLIVAN, GONZALEZ, LIU

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MLTSPNSR

&nbsp

Amd §§4902 & 4903, Pub Health L; amd §§4902 & 4903, Ins L

&nbsp

Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; relates to prescription drug formulary changes and pre-authorization for certain health care services.

Go to top S09651 Actions:

BILL NOS09651 

&nbsp

03/31/2026REFERRED TO HEALTH

04/21/20261ST REPORT CAL.815

04/22/20262ND REPORT CAL.

04/27/2026ADVANCED TO THIRD READING 

06/05/2026COMMITTED TO RULES

Go to topS09651 Committee&nbspVotes:

Go to topS09651 Floor&nbspVotes:

There are no Assembly votes for this bill in this legislative session.

Go to topS09651 Text:

 STATE OF NEW YORK
 ________________________________________________________________________

 9651

 IN SENATE

 March 31, 2026
 ___________

 Introduced by Sen. RIVERA -- read twice and ordered printed, and when
 printed to be committed to the Committee on Health

 AN ACT to amend the public health law and the insurance law, in relation
 to utilization review program standards and pre-authorization of
 health care services

 The People of the State of New York, represented in Senate and Assem-
 bly, do enact as follows:

 1 Section 1. Paragraph (c) of subdivision 1 of section 4902 of the
 2 public health law, as added by chapter 705 of the laws of 1996, is
 3 amended to read as follows:
 4 (c) Utilization of written clinical review criteria developed pursuant
 5 to a utilization review plan. Such clinical review criteria shall
 6 utilize recognized evidence-based and peer reviewed clinical review
 7 criteria that take into account the needs of a typical patient popu-
 8 lations and diagnoses;
 9 § 2. Paragraph (a) of subdivision 2 of section 4903 of the public
 10 health law, as separately amended by section 13 of part YY and section 3
 11 of part KKK of chapter 56 of the laws of 2020, is amended to read as
 12 follows:
 13 (a) A utilization review agent shall make a utilization review deter-
 14 mination involving health care services which require pre-authorization
 15 and provide notice of a determination to the enrollee or enrollee's
 16 designee and the enrollee's health care provider by telephone and in
 17 writing within [three business days] seventy-two hours of receipt of the
 18 necessary information, within twenty-four hours of the receipt of neces-
 19 sary information if the request is for an enrollee with a medical condi-
 20 tion that places the health of the insured in serious jeopardy without
 21 the health care services recommended by the enrollee's health care
 22 professional, or for inpatient rehabilitation services following an
 23 inpatient hospital admission provided by a hospital or skilled nursing
 24 facility, within one business day of receipt of the necessary informa-
 25 tion. The notification shall identify[;]: (i) whether the services are
 26 considered in-network or out-of-network; (ii) and whether the enrollee
 27 will be held harmless for the services and not be responsible for any

 EXPLANATION--Matter in italics (underscored) is new; matter in brackets
 [ ] is old law to be omitted.
 LBD07503-01-5

 S. 9651 2

 1 payment, other than any applicable co-payment or co-insurance; (iii) as
 2 applicable, the dollar amount the health care plan will pay if the
 3 service is out-of-network; and (iv) as applicable, information explain-
 4 ing how an enrollee may determine the anticipated out-of-pocket cost for
 5 out-of-network health care services in a geographical area or zip code
 6 based upon the difference between what the health care plan will reim-
 7 burse for out-of-network health care services and the usual and custom-
 8 ary cost for out-of-network health care services. An approval for a
 9 request for pre-authorization shall be valid for (1) the duration of the
 10 prescription, including any authorized refills and (2) the duration of
 11 treatment for a specific condition as requested by the enrollee's health
 12 care provider.
 13 § 3. Paragraph 3 of subsection (a) of section 4902 of the insurance
 14 law, as added by chapter 705 of the laws of 1996, is amended to read as
 15 follows: