On August 1, 2007, New York’s Governor Spitzer signed into law S.3986-A, a bill intended to decrease friction between managed care plans and their participating providers on certain sensitive issues. Most significantly, if a health plan requires that certain health care services be preauthorized in order to be covered, then once a service has been preauthorized and performed, the plan may not thereafter deny coverage for the service. Exceptions are made in special circumstances, however, such as when the patient’s eligibility lapsed before the services were provided or the preauthorization was based on inadequate or incomplete information. The legislation also addresses the brinksmanship that can occur when the expiration of a participation contract approaches and renewal terms have not been reached. It provides for a two month “cooling off” period after the contract terminates or expires, during which the parties must continue to abide by the terms of the contract, and provides for advance notification to enrollees of possible changes in their provider network.
The legislation also places a time limit of fifteen months for out-of-network providers to submit claims for Medicaid Managed Care, Child Health Plus and Family Health Plus; and provides patients with a right to appeal to an independent reviewer when their health plan denies an out-of-network claim. The bill was the product of negotiations between health care provider associations, certain medical specialty societies, and health plan associations.
