New York Assembly Bill A04063

New York 2025-2026 Regular Session

• Introduced: 1/31/25
• Refer: 1/31/25
• Refer: 1/7/26

Caption

Provides that the failure by the utilization review agent to make a determination within certain time periods shall be deemed to be an approval of the health care services.

Summary

This bill changes New York’s utilization review rules so that if a utilization review agent does not issue a decision within the required time frame, the request for health care services is treated as approved rather than as an adverse determination. The bill applies this rule in both the Public Health Law and the Insurance Law, and it also preserves special treatment for step therapy protocols by providing that missed deadlines in that context are deemed an override of the step therapy requirement. The measure also states that a utilization review agent’s failure to comply with certain step therapy protocol requirements can itself be a basis for granting a step therapy override, unless fraud is involved. In effect, the bill strengthens patient and provider rights when insurers or managed care plans miss statutory review deadlines, while keeping the existing appeal framework and step therapy override structure in place.

Impact

The bill amends section 4903 of the Public Health Law and subsection (g) of section 4903 of the Insurance Law, reversing the current default consequence for missed utilization review deadlines from an adverse determination to an approval of the requested services. It also updates related step therapy provisions so that deadline failures and certain procedural failures can trigger an override of the step therapy protocol. The practical effect is to impose stricter compliance incentives on health plans, utilization review agents, and insurers, while improving access to covered care for patients and providers when determinations are delayed.

Sentiment

The available materials show no recorded committee debate or votes, so there is no documented split in the legislative record provided. Based on the bill’s caption and text, the measure appears to be framed positively as a patient-access and administrative accountability bill, with an emphasis on preventing delays in medical decision-making. The absence of opposition testimony or vote history means the overall sentiment cannot be measured directly from the provided context, but the bill’s structure suggests support for stronger consumer protections in health coverage reviews.

Contention

The main policy tension is between patient access to timely care and insurer/utilization review control over medical necessity determinations. Supporters would likely favor the automatic approval remedy as a way to deter missed deadlines and reduce delays, while opponents may argue it could force approval of services without a completed medical review and increase costs or reduce utilization management flexibility. A secondary point of contention is the step therapy override language, which further limits insurer discretion by allowing procedural failures to justify bypassing step therapy requirements.