Bill > A06648

This bill addresses several key provisions related to health insurance utilization review and medical necessity determinations. It defines "medical necessity" as a health care service that prevents, diagnoses, or treats an illness, must be in accordance with medical and scientific evidence, clinically appropriate, and not primarily for economic benefit. The bill expands the definition of emergency services to explicitly include mental health and substance use disorder services provided by mobile crisis teams or crisis centers. It requires that utilization review agents use peer-reviewed clinical review criteria that are fully consistent with medical and scientific evidence, and mandates that these criteria publicly identify all authors, reviewers, and editors involved in their development. The bill also prohibits health plans from reversing previous medical necessity determinations through retrospective reviews or claim audits (except in cases of fraud) and prevents downgrading or bundling claim codes in a way that would effectively alter a previous medical necessity determination. Additionally, the bill provides a comprehensive definition of mental health and substance use disorders, referencing diagnostic categories from the World Health Organization and American Psychiatric Association, and ensures that changes in terminology do not impact coverage as long as the condition is commonly understood by healthcare providers. The overall aim is to create more transparent, scientifically-grounded, and patient-centered approaches to medical coverage and treatment authorization.

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https://www.nysenate.gov/legislation/bills/2025/A6648