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S 9651

Relates to utilization review program standards and pre-authorization for certain health care services

2025 Regular Session Introduced by Joe Addabbo and 6 co-sponsors

S. 9651 standardizes utilization reviews to use evidence-based criteria, expands pre-authorization notice details, and speeds urgent determinations to improve transparency and acce

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Bill Summary · S 9651

Summary of Bill S. 9651 (2025-2026) – New York

Purpose and Intent

  • Relates to utilization review program standards and pre-authorization for certain health care services.
  • Requires utilization review criteria to be evidence-based and peer-reviewed, reflecting standard practices for evaluating the necessity and scope of medical services.
  • Aims to make pre-authorization decisions more transparent to enrollees and providers and to align review processes with recognized clinical guidance.

Key Provisions

Utilization Review Criteria (Public Health Law and Insurance Law)

  • Utilization review criteria must use recognized evidence-based and peer-reviewed clinical criteria that consider typical patient populations and diagnoses. This applies to plans subject to utilization review requirements.

Pre-Authorization Determinations (Notice and Standards)

  • When a utilization review agent makes a pre-authorization determination for health care services, the agent must provide notice to the enrollee (or designee) and the enrollee’s health care provider by telephone and in writing within:
    • 72 hours of receiving the necessary information (standard timeline).
    • 24 hours if the request involves an enrollee with a medical condition placing health in serious jeopardy without the recommended services.
    • 1 business day in the case of inpatient rehabilitation services following an inpatient hospital admission (hospital or skilled nursing facility).
  • The notification must include:
    • Whether the services are in-network or out-of-network.
    • Whether the enrollee will be held harmless for payments beyond any applicable co-payment or co-insurance (and deductible where applicable).
    • The dollar amount the health plan will pay if the service is out-of-network.
    • Information on how the enrollee can estimate out-of-pocket costs for out-of-network services in a given geographic area (based on the difference between what the plan will reimburse and the usual and customary cost for out-of-network services).
  • An approval for pre-authorization is valid for:
    • The duration of the prescription (including refills), and
    • The duration of treatment for the specific condition as requested by the enrollee’s health care provider.

Insurance Law Parallels

  • The same standards and timelines apply to utilization review determinations for services requiring pre-authorization under the Insurance Law, mirroring the Public Health Law provisions.

Who Is Affected

  • Health plans and utilization review agents operating under New York law (both public health law and insurance law frameworks).
  • Enrollees and their health care providers who seek or rely on pre-authorization for medical services.
  • Inpatient rehabilitation services and related inpatient hospital or skilled nursing facility settings are specifically covered under shortened review timelines.

Timelines and Effective Date

  • Effective date: 180 days after enactment.
  • The bill outlines specific response times for pre-authorization determinations (72 hours standard; 24 hours in urgent cases; 1 business day for inpatient rehab after admission).

Practical Impact

  • Increased use of evidence-based, peer-reviewed criteria for determining the necessity of services.
  • More transparent communication to enrollees about in-network status, cost-sharing responsibility, and potential out-of-network costs.
  • Potentially faster access to urgent services (24-hour window for serious jeopardy scenarios).
  • Clear alignment between public health and insurance law criteria, ensuring consistency across regulatory framework.
  • Enrollees receive explicit information to help estimate potential out-of-pocket costs for out-of-network services.

Summary

S. 9651 seeks to standardize and strengthen utilization reviews by enforcing evidence-based criteria, clarifying pre-authorization notification content, and accelerating response times in urgent cases. It enhances transparency around network status and financial responsibility and extends parity between public health and insurance law procedures.

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

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