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Bill

A 7292

Directs a health maintenance organization which denies a claim due to absence of medical necessity to advise insured as to alternative treatment

2025 Regular Session Introduced by Gary Pretlow

Requires HMOs to advise insureds of alternative treatment options after a denial for lack of medical necessity, boosting transparency and access to care.

REFERRED TO INSURANCE
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WeVote Research Nonpartisan
Bill Summary · A 7292

Summary of Assembly Bill A 7292

Overview

Bill A 7292 would require a health maintenance organization (HMO) to advise an insured about alternative treatment options when a claim is denied on the basis of absence of medical necessity. The measure focuses on ensuring that insured individuals receive information about viable alternatives after a denial, potentially improving access to care and options for patients.

Purpose and Intent

  • Improve transparency and patient information when a claim is denied for lack of medical necessity.
  • Ensure insureds understand possible alternative treatments their plan could cover or refer to, potentially reducing confusion and delays in care.
  • Align insurer denial practices with consumer-protection goals by prompting proactive guidance to members.

Key Provisions (as described)

  • Applies to health maintenance organizations experiencing a denial of a claim due to absence of medical necessity.
  • Obliges the HMO to advise the insured of alternative treatment options appropriate to the insured’s condition.
  • The bill specifies the relationship between denial determinations and subsequent patient guidance, though exact procedural details (form, timing, or required content of the advisory) are not provided in the available information.

Note: The summary reflects the bill’s stated objective based on its title. Specific provisions (e.g., notice content, appeal interplay, or enforcement mechanisms) are not detailed in the provided text.

Who Would Be Affected

  • Primary: Members/insureds enrolled in HMOs who have a claim denied for non-necessity.
  • Secondary: HMOs and their administrative/claims personnel responsible for determinations and member communications; healthcare providers who may discuss alternative options with patients following a denial.

Procedural and Timeline Aspects

  • Introduced: March 25, 2025.
  • Status: REFERRED TO INSURANCE.
  • Legislative Actions noted: Referred to Insurance on March 25, 2025 (listed twice in the provided actions).
  • No further committee passage or floor vote information is provided.

Related Legislation

  • Related bills from prior sessions include A 1942, A 3505, A 2843, A 2571, A 4505, A 766, A 4103, A 1825, and A 4772. The existence of multiple related measures suggests ongoing interest in consumer protections surrounding insurance determinations and treatment options.

Potential Impacts

  • Positive: Enhanced patient awareness of alternative treatment paths after denial; potential to reduce treatment delays, improve satisfaction, and support informed medical decision-making.
  • Administrative: Could impose additional communication requirements on HMOs; potential variation in how notices and advisories are delivered.
  • Practical considerations: The bill’s effectiveness will depend on the specifics of implementation (timing, exact content, and enforcement).

Next Steps

  • Await committee action by the Insurance committee for NRC/markup, voting, or amendments.
  • Monitor for any updates on status, potential amendments, or related amendments in response to stakeholders.

Compiled from official sources — confirm details with the bill’s official record.

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