New York Assembly Bill A03789

New York 2025-2026 Regular Session

• Introduced: 1/30/25
• Refer: 1/30/25
• Report Pass: 5/28/25
• Refer: 5/28/25
• Refer: 1/7/26

Caption

Relates to utilization review program standards; requires use of evidence-based and peer reviewed clinical review criteria; relates to prescription drug formulary changes and pre-authorization for certain health care services.

Impact

The implementation of A03789 is likely to streamline the process surrounding the pre-authorization of health care services, which many patients and providers have found cumbersome. The bill specifies that determinations for pre-authorization should be made promptly, within a defined period, to reduce delays in access to necessary care. By enhancing the accountability of utilization review agents and introducing clearer timeframes for notifications of determinations, the bill seeks to improve both efficiency in healthcare delivery and the patient experience within the state's healthcare system.

Summary

Bill A03789 introduces significant amendments to the public health law and the insurance law, aimed at enhancing the standards for utilization review programs. Central to the bill is the requirement for utilization review agents to utilize evidence-based and peer-reviewed clinical review criteria, ensuring that decisions about healthcare services are made transparently and based on sound medical evidence. By mandating that these criteria consider the needs of typical patient populations and diagnoses, the bill aims to better align healthcare delivery with patient requirements.

Contention

While there is support for the bill, particularly among those promoting quality and efficiency in health care, there are concerns regarding the implications for access to services. Some stakeholders argue that the stringent adherence to clinical review criteria may limit flexibility in individual patient cases, potentially hindering the ability of healthcare providers to make personalized treatment decisions. As the bill moves through the legislative process, discussions are expected to focus on balancing standardized care with the necessity of accommodating specific patient needs.