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S 5241

Relates to utilization review determinations

2025 Regular Session Introduced by Joe Addabbo and 4 co-sponsors

S 5241 proposes changes to how insurers conduct utilization reviews, including criteria, communication, and appeal processes for approvals or denials of medical services.

REFERRED TO INSURANCE
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Bill Summary · S 5241

Summary of Senate Bill S 5241 – Relates to utilization review determinations

Overview

  • Bill number: S 5241
  • Title: Relates to utilization review determinations
  • Status: Referred to the Insurance Committee
  • Introduced: February 20, 2025
  • Classification: Bill (legislation)

This bill, by its title, addresses utilization review determinations. The exact text and provisions are not provided in the materials available here, so the summary focuses on what is known from the bill’s metadata and typical subject matter associated with utilization review.

Purpose and intent (as suggested by the title)

  • The bill appears to relate to how utilization review decisions are made by health insurers or health plans. Utilization review generally involves evaluating the necessity, appropriateness, and efficiency of medical services and treatments, often finalizing determinations on preauthorization, denials, and approvals.
  • The specific objectives, standards, criteria, timelines, and enforcement mechanisms would be set forth in the bill’s text (not included in the provided materials).

Key provisions (not yet available in the provided text)

  • The exact provisions are not included in the materials provided. Potential topics that such a bill could address, based on common utilization review reforms, might include:
    • Transparent criteria for approvals, denials, and rationale required to be communicated to patients and providers.
    • Requirements for timelines and notice standards for determinations.
    • Rights to appeal or external review of adverse determinations.
    • Reporting and accountability measures for insurers or health plans.
    • Provisions governing the use of standardized review processes or independent review organizations.

Note: The above points are typical areas in utilization review reform but should not be construed as confirmed provisions of S 5241 without the actual bill text.

Affected parties

  • Insurers and health plans subject to utilization review determinations.
  • Healthcare providers who rely on insurer determinations for patient care authorization.
  • Patients and enrollees who receive utilization review decisions (e.g., preauthorization denials or approvals).
  • Potentially, consumer protection and oversight bodies responsible for monitoring insurance practices.

Procedural status and timeline

  • Introduced: February 20, 2025.
  • Committee assignment: Referred to the Insurance Committee (the only listed action in the materials).
  • The materials also show a companion Assembly bill: A 6648 (noted twice as a companion).

Related legislation

  • Companion bill in the Assembly: A 6648 (listed as a companion bill). This indicates parallel legislation moving through another chamber, which often accompanies a Senate bill for harmonization.

Next steps / what to monitor

  • Obtain the full bill text to confirm the exact provisions, standards, and any deadlines or enforcement mechanisms.
  • Track amendments and committee hearings in the Senate Insurance Committee.
  • Compare S 5241 with its Assembly companion A 6648 to identify alignment or differences that may affect passage.
  • Monitor amendments that address transparency, appeal rights, external review, and compliance timelines.

If you’d like, I can compare this bill’s stated sponsor list to related bills or provide a side-by-side with the Assembly companion once the full texts are available.

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

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