Bill > S05241

This bill makes several important changes to insurance and public health laws regarding utilization review (the process of evaluating the medical necessity and appropriateness of healthcare services). The bill establishes a more comprehensive definition of "medically necessary" services, requiring that covered healthcare services must be in accordance with medical and scientific evidence, clinically appropriate, and not primarily for economic benefit or convenience. It expands the definition of emergency services to explicitly include mental health and substance use disorder services provided by mobile crisis teams or crisis centers, and prevents health plans from denying emergency service payments unless they can prove the services were never actually performed. The bill also requires utilization review agents to use peer-reviewed clinical review criteria that are fully consistent with medical and scientific evidence, and mandates transparency by requiring these tools to publicly identify all authors, reviewers, and editors involved in their development. Additionally, the bill prohibits health plans from reversing previous medical necessity determinations through retrospective reviews or claim audits, and prevents downgrading or bundling claim codes in a way that would effectively alter an earlier medical necessity determination. These provisions aim to protect patients by ensuring that healthcare coverage decisions are based on robust medical evidence and clinical standards, with a particular focus on improving access to mental health and substance use disorder treatments.

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https://www.nysenate.gov/legislation/bills/2025/S5241