S 10268 NY
Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstance
A state bill is a proposed law in a state legislature — separate from the U.S. Congress. Learn more →
Summary
This bill requires health insurance companies and health plans to automatically approve certain health care services from professionals with strong approval records. If an insurer has approved at least ninety percent of preauthorization requests from a health care professional for a specific service in the most recent six-month evaluation period, that professional automatically receives approval for future requests for that service without additional review. Once a health care professional qualifies for automatic preauthorization approval, the insurer must promptly issue approval and payment when the professional submits preauthorization requests, and cannot deny, withhold, or reduce payment based on medical necessity after granting the automatic approval. The automatic approval can only be rescinded in January of each year and only if less than ninety percent of the professional's claims met medical necessity criteria, with thirty days notice and the opportunity to appeal required before rescission takes effect. The bill applies to both insurance companies and health plans in New York.
AI-generated plain-language summary of the bill text — neutral, and may be imperfect. See the full text below for the exact wording.
Official abstract
Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstances.
Sponsor (1)
- James Skoufis Democratic · primary
Action history (1)
- May 11, 2026 REFERRED TO INSURANCE · upper
Text versions (2)
Full text
Full text imported from assembly.state.ny.us
Skip to main content
New York State Assembly Speaker Carl E. Heastie
--> --> -->
Assembly Members
Legislative Info
Public Hearings
Speaker's Press
Assembly Reports
Committees & More
Bill Search Home Laws Legislative Calendar Public Hearing Schedule Assembly Calendars Assembly Committee Agenda Javascript must be enabled to properly view this page.
Bill No.: Summary Actions Committee Votes Floor Votes Memo Text LFIN Chamber Video/Transcript S10268 Summary: BILL NO S10268   SAME AS No Same As   SPONSOR SKOUFIS   COSPNSR   MLTSPNSR   Amd §4902, Ins L; amd §4902, Pub Health L   Requires insurers and health plans to grant automatic preauthorization approvals to eligible health care professionals in certain circumstances.
Go to top S10268 Text:
STATE OF NEW YORK ________________________________________________________________________
10268
IN SENATE
May 11, 2026 ___________
Introduced by Sen. SKOUFIS -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law and the public health law, in relation to requiring insurers and health plans to grant automatic preauthori- zation approvals to eligible health care professionals in certain circumstances
The People of the State of New York, represented in Senate and Assem- bly, do enact as follows:
1 Section 1. Subsection (a) of section 4902 of the insurance law is 2 amended by adding a new paragraph 17 to read as follows: 3 (17) Establishment of automatic preauthorization approval requirements 4 for insurers to provide to health care professionals providing health 5 care services which shall include that: 6 (i) an insurer that uses a preauthorization process for health care 7 services shall provide an automatic preauthorization approval to a 8 health care professional for a particular health care service, as 9 defined under this title including but not limited to health care proce- 10 dures, treatments, services, pharmaceutical products, services or dura- 11 ble medical equipment if, in the most recent six-month evaluation peri- 12 od, the insurer has approved not less than ninety percent of the 13 preauthorization requests submitted by such health care professional for 14 the particular health care service. For the purposes of this require- 15 ment, a preauthorization request submitted during the evaluation period 16 shall be considered and counted as a single request and single approval 17 if the request was approved at any point between the date the request 18 was submitted by the health care professional and the final determi- 19 nation by the insurer, including any re-review or appeal process. Each 20 insurer shall complete its initial evaluation and issue its determi- 21 nation to each health care professional in its network no later than one 22 hundred eighty days after the effective date of this paragraph. The 23 automatic preauthorization approval shall become effective two hundred 24 twenty-five days after the effective date of this paragraph; 25 (ii) after the initial evaluation has been completed the insurer shall 26 annually thereafter evaluate whether a health care professional quali-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD01540-02-5
S. 10268 2
1 fies for an automatic preauthorization approval under subparagraph (i) 2 of this paragraph for additional health care services. Each year, the 3 evaluation shall review preauthorization determinations made in the 4 first six months of the year. Each insurer shall issue its determination 5 to each health care professional in its network no later than November 6 fifteenth to be effective January first of the following year; 7 (iii) the insurer may continue the automatic preauthorization approval 8 under subparagraph (i) of this paragraph without evaluating whether the 9 health care professional qualifies for automatic preauthorization 10 approval for a particular evaluation period; 11 (iv) a health care professional shall not be required to request an 12 automatic preauthorization approval to qualify for such approval; 13 (v) a health care professional's automatic preauthorization approval 14 under subparagraph (i) of this paragraph shall remain in effect until 15 the thirtieth calendar day after: 16 (A) the date the insurer notifies the health care professional of the 17 insurer's determination to rescind the automatic preauthorization 18 approval pursuant to subparagraph (vii) of this paragraph if the health 19 care professional does not appeal such determination; or 20 (B) where the health care professional appeals the determination, the 21 date the insurer notifies the health care professional that an independ- 22 ent review organization has affirmed the insurer's determination to 23 rescind the automatic preauthorization approval; 24 (vi) where an insurer does not finalize a rescission determination as 25 specified in subparagraph (vii) of this paragraph, the health care 26 professional shall be considered to have met the criteria to continue to 27 qualify for the automatic preauthorization approval, which shall remain 28 in effect until the following evaluation period; 29 (vii) an insurer may rescind an automatic preauthorization approval 30 under subparagraph (i) of this paragraph only: 31 (A) effective January of each year; 32 (B) if the insurer makes a determination on the basis of a retrospec- 33 tive review as specified in subparagraph (ii) of this paragraph for the 34 most recent evaluation period that less than ninety percent of the 35 claims for the particular health care service met the medical necessity 36 criteria that would have been used by the insurer when conducting preau- 37 thorization review for the particular health care service during the 38 relevant evaluation period; and 39 (C) the insurer complies with all other applicable requirements of 40 this paragraph and the insurer notifies the health care professional not 41 less than thirty calendar days before the proposed rescission is to take 42 effect, together with the sample of claims used to make the determi- 43 nation pursuant to clause (B) of this subparagraph and a plain language 44 explanation of the health care professional's right to appeal such 45 determination and instructions on how to initiate such appeal; 46 (viii) notwithstanding any contrary provision of subparagraph (i) of 47 this paragraph, an insurer may deny an automatic preauthorization 48 approval: 49 (A) if the health care professional does not have the approval at the 50 time of the relevant evaluation period; and 51 (B) the insurer provides the health care professional with actual 52 statistics and data for the relevant preauthorization request evaluation 53 period and detailed information sufficient to demonstrate that the 54 health care professional does not meet the criteria for an automatic 55 preauthorization approval pursuant to subparagraph (i) of this paragraph 56 for the particular health care service;
S. 10268 3
1 (ix) after a final determination or review affirming the rescission or 2 denial of an automatic preauthorization approval for a specific health 3 care service under this paragraph, a health care professional shall be 4 eligible for consideration of such approval for the same health care 5 service after the evaluation period following the evaluation period 6 which formed the basis of the rescission or denial of such approval; 7 (x) the insurer shall, not later than five business days after deter- 8 mining that a health care professional qualifies for an automatic preau- 9 thorization approval pursuant to subparagraph (i) of this paragraph, 10 provide to a health care professional a notice that shall include: 11 (A) a statement that the health care professional qualifies for an 12 automatic preauthorization approval pursuant to this paragraph; 13 (B) a description of the health care services to which such automatic 14 preauthorization applies; and 15 (C) a statement of the duration that such automatic approval shall 16 remain in effect; 17 (xi) when the health care professional submits a preauthorization 18 request for a health care service for which the health care professional 19 qualifies for an automatic preauthorization approval under subparagraph 20 (i) of this paragraph, the insurer shall promptly issue an automatic 21 preauthorization approval for such health care service; 22 (xii) nothing in this paragraph may be construed to: 23 (A) authorize a health care professional to provide a health care 24 service outside the scope of such health care professional's applicable 25 license; or 26 (B) prohibit a health insurer from performing a retrospective review 27 of the health care service pursuant to section forty-nine hundred three 28 of this title; 29 (xiii) when a health care professional provides a health care service 30 covered by the health care professional's automatic preauthorization 31 approval, the service is deemed medically necessary by virtue of the 32 automatic preauthorization approval. For every claim submitted by a 33 health care professional for such service, each insurer shall promptly 34 pay the full payment to the health care professional. An insurer is 35 prohibited from denying, withholding, or reducing payment to a health 36 care professional for such health care service. An insurer may not 37 retroactively deny, reduce, or recoup payment from a health care profes- 38 sional for such health care service for reasons related to medical 39 necessity or appropriateness of care; 40 (xiv) an insurer may not retroactively deny, reduce, or recoup payment 41 from a health care professional for a health care service for which the 42 health care professional has qualified for an automatic preauthorization 43 approval under subparagraph (i) of this paragraph unless the insurer has 44 proven that the health care professional: 45 (A) knowingly and materially misrepresented the health care service in 46 a request for preauthorization or payment submitted to the insurer with 47 the specific intent to deceive and obtain an unlawful payment from the 48 insurer; or 49 (B) failed to substantially perform the health care service; 50 (xv) an insurer may not retroactively deny, reduce or recoup payment 51 from a health care professional for a health care service for which the 52 health care professional has qualified for an automatic preauthorization 53 approval solely on the basis of the rescission of the health care 54 professional's automatic preauthorization approval. Nothing herein shall 55 limit a health care professional's ability to file a complaint with the 56 department;
S. 10268 4
1 (xvi) the insurer shall make available and submit to the superinten- 2 dent, at the superintendent's request, documentation that describes the 3 insurer's process for: 4 (A) determining the specific health care service or services for which 5 an individual health care professional is granted an automatic preau- 6 thorization approval; and 7 (B) any other activity, policy, decision, or determination related to 8 automatic preauthorization approvals; and 9 (xvii) the superintendent shall promulgate regulations to implement 10 the requirements of this section and establish additional minimum stand- 11 ards as appropriate. 12 § 2. Subdivision 1 of section 4902 of the public health law is amended 13 by adding a new paragraph (m) to read as follows: 14 (m) Establishment of automatic preauthorization approval requirements 15 for health care plans to provide to health care professionals providing 16 certain health care services which shall include that: 17 (i) a health care plan that uses a preauthorization process for health 18 care services shall provide an automatic preauthorization approval to a 19 health care professional for a particular health care service if, as 20 defined under this title including but not limited to health care proce- 21 dures, treatments, services, pharmaceutical products, services or dura- 22 ble medical equipment, in the most recent six-month evaluation period, 23 the health care plan has approved not less than ninety percent of the 24 preauthorization requests submitted by such health care professional for 25 the particular health care service. For the purposes of this require- 26 ment, a preauthorization request submitted during the evaluation period 27 shall be considered and counted as a single request and single approval 28 if the request was approved at any point between the date the request 29 was submitted by the health care professional and the final determi- 30 nation by the health care plan, including any re-review or appeal proc- 31 ess. Each insurer shall complete its initial evaluation and issue its 32 determination to each health care professional in its network no later 33 than one hundred eighty days after the effective date of this paragraph. 34 The automatic preauthorization approval shall become effective two 35 hundred twenty-five days after the effective date of this paragraph; 36 (ii) after the initial evaluation has been completed the health care 37 plan shall annually thereafter evaluate whether a health care profes- 38 sional qualifies for an automatic preauthorization approval under 39 subparagraph (i) of this paragraph for additional health care services. 40 Each year, the evaluation shall review preauthorization determinations 41 made in the first six months of the year. Each health care plan shall 42 issue its determination to each health care professional in its network 43 no later than November fifteenth to be effective January first of the 44 following year; 45 (iii) the health care plan may continue the automatic preauthorization 46 approval under subparagraph (i) of this paragraph without evaluating 47 whether the health care professional qualifies for the automatic preau- 48 thorization approval for a particular evaluation period; 49 (iv) a health care professional shall not be required to request an 50 automatic preauthorization approval to qualify for such approval; 51 (v) a health care professional's automatic preauthorization approval 52 under subparagraph (i) of this paragraph shall remain in effect until 53 the thirtieth calendar day after: 54 (A) the date the health care plan notifies the health care profes- 55 sional of the health care plan's determination to rescind the automatic 56 preauthorization approval pursuant to subparagraph (vii) of this para-
S. 10268 5
1 graph if the health care professional does not appeal such determi- 2 nation; or 3 (B) where the health care professional appeals the determination, the 4 date the health care plan notifies the health care professional that an 5 independent review organization has affirmed the health care plan's 6 determination to rescind the automatic preauthorization approval; 7 (vi) where a health care plan does not finalize a rescission determi- 8 nation as specified in subparagraph (vii) of this paragraph, the health 9 care professional shall be considered to have met the criteria to 10 continue to qualify for the automatic preauthorization approval, which 11 shall remain in effect until the following evaluation period; 12 (vii) a health care plan may rescind an exemption from preauthori- 13 zation requirements under subparagraph (i) of this paragraph only: 14 (A) effective January each year; 15 (B) if the health care plan makes a determination on the basis of a 16 retrospective review as specified in subparagraph (ii) of this paragraph 17 for the most recent evaluation period that less than ninety percent of 18 the claims for the particular health care service met the medical neces- 19 sity criteria that would have been used by the health care plan when 20 conducting preauthorization review for the particular health care 21 service during the relevant evaluation period; and 22 (C) the health care plan complies with all other applicable require- 23 ments of this paragraph and the health care plan notifies the health 24 care professional not less than thirty calendar days before the proposed 25 rescission is to take effect, together with the sample of claims used to 26 make the determination pursuant to clause (B) of this subparagraph and a 27 plain language explanation of the health care professional's right to 28 appeal such determination and instructions on how to initiate such 29 appeal; 30 (viii) notwithstanding any contrary provision of subparagraph (i) of 31 this paragraph, a health care plan may deny an automatic preauthori- 32 zation approval: 33 (A) if the health care professional does not have the approval at the 34 time of the relevant evaluation period; and 35 (B) the health care plan provides the health care professional with 36 actual statistics and data for the relevant preauthorization request 37 evaluation period and detailed information sufficient to demonstrate 38 that the health care professional does not meet the criteria for an 39 automatic preauthorization approval pursuant to subparagraph (i) of this 40 paragraph for the particular health care service; 41 (ix) after a final determination or review affirming the rescission or 42 denial of an automatic preauthorization approval for a specific health 43 care service under this paragraph, a health care professional shall be 44 eligible for consideration of such approval for the same health care 45 service after the evaluation period following the evaluation period 46 which formed the basis of the rescission or denial of such approval; 47 (x) the health care plan shall, not later than five business days 48 after determining that a health care professional qualifies for an auto- 49 matic preauthorization approval pursuant to subparagraph (i) of this 50 paragraph, provide to a health care professional a notice that shall 51 include: 52 (A) a statement that the health care professional qualifies for an 53 automatic preauthorization approval pursuant to this paragraph; 54 (B) a description of the health care services to which such automatic 55 preauthorization approval applies; and
S. 10268 6
1 (C) a statement of the duration that such automatic approval shall 2 remain in effect; 3 (xi) when the health care professional submits a preauthorization 4 request for a health care service for which the health care professional 5 qualifies for an automatic preauthorization approval under subparagraph 6 (i) of this paragraph, the health care plan shall promptly issue an 7 automatic preauthorization approval for such health care service; 8 (xii) nothing in this paragraph shall be construed to: 9 (A) authorize a health care professional to provide a health care 10 service outside the scope of such health care professional's applicable 11 license; or 12 (B) prohibit a health care plan from performing a retrospective review 13 of the health care service pursuant to section forty-nine hundred three 14 of this title; 15 (xiii) when a health care professional provides a health care service 16 covered by the health care professional's automatic preauthorization 17 approval, the service is deemed medically necessary by virtue of the 18 automatic preauthorization approval. For every claim submitted by a 19 health care professional for such service, each health care plan shall 20 promptly pay the full payment to the health care professional. A health 21 care plan is prohibited from denying, withholding, or reducing payment 22 to a health care professional for such health care service. A health 23 care plan may not retroactively deny, reduce, or recoup payment from a 24 health care professional for such health care service for reasons 25 related to medical necessity or appropriateness of care; 26 (xiv) a health care plan may not retroactively deny, reduce, or recoup 27 payment from a health care professional for a health care service for 28 which the health care professional has qualified for an automatic preau- 29 thorization approval under subparagraph (i) of this paragraph unless the 30 health care plan has proven that the health care professional: 31 (A) knowingly and materially misrepresented the health care service in 32 a request for preauthorization or payment submitted to the health care 33 plan with the specific intent to deceive and obtain an unlawful payment 34 from the health care plan; or 35 (B) failed to substantially perform the health care service; 36 (xv) a health care plan may not retroactively deny, reduce or recoup 37 payment from a health care professional for a health care service for 38 which the health care professional has qualified for an automatic preau- 39 thorization approval solely on the basis of the rescission of the health 40 care professional's automatic preauthorization approval. Nothing herein 41 shall limit a health care professional's ability to file a complaint 42 with the department; 43 (xvi) the health care plan shall make available and submit to the 44 commissioner, at the commissioner's request, documentation that 45 describes the health care plan's process for: 46 (A) determining the specific health care service or services for which 47 an individual health care professional is granted an automatic preau- 48 thorization approval; and 49 (B) any other activity, policy, decision, or determination related to 50 automatic preauthorization approvals; and 51 (xvii) the commissioner, in consultation with the superintendent, 52 shall promulgate regulations to implement the requirements of this 53 section and establish additional minimum standards as appropriate. 54 § 3. This act shall take effect on the one hundred eightieth day after 55 it shall have become a law.
Go to top
Sitemap
Request Information
Directions and Maps
Comments
Data from OpenStates. View on OpenStates →
Comments