New York Senate Bill S09651

New York 2025-2026 Regular Session

• Introduced: 3/31/26
• Refer: 3/31/26

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

If passed, S09651 would affect how insurance companies and healthcare providers conduct utilization reviews by mandating more stringent timelines for issuing determinations. For example, the bill specifies that healthcare providers must be notified of pre-authorization decisions within 24 hours when the request involves patients whose health is potentially at serious risk. This change is designed to expedite access to necessary medical services and reduce delays in treatment, which can be critical for various medical conditions.

Summary

Bill S09651 pertains to the standards for utilization review programs within the healthcare system of New York State. This proposed legislation aims to amend existing public health laws and insurance regulations to establish clearer guidelines around utilization reviews and pre-authorization processes for healthcare services. A significant focus of the bill is the implementation of evidence-based and peer-reviewed clinical review criteria that healthcare providers must adhere to. This objective is to ensure that decisions about medical necessity are based on recognized best practices and accurate patient need analyses.

Contention

Throughout the legislative discussions, there may be points of contention regarding the adequacy of the proposed timeframes for review and whether they sufficiently address the complexities involved in some medical cases. Advocates for the bill argue that it will facilitate quicker access to necessary treatments for patients and enhance transparency in healthcare decision-making. However, detractors may raise concerns about how these changes could affect insurance companies' review processes and financial implications for them during the transition to these new standards.