New York seniors in managed care programs will soon be protected by new provisions passed by Governor David Paterson. The Act, passed earlier this year, goes into effect tomorrow. The Health Care Association of New York helped shape the legislation and “advocated for its enactment to end onerous managed care market conduct and enable providers to appeal managed care coverage denials on behalf of patients.”

Some of the key provisions:

  • Providers have the right to make “retrospective and concurrent external appeals” following an adverse determination.
  • Insurers are prohibited from denying a claim on the basis that it is coordinating benefits and another insurer is liable for payment.
  • The law prohibits managed care plans from considering a participating hospital or health care provider’s services as out-of-network solely because the treating physician is not a participating provider.
  • Overpayment recovery protections will be extended to all health care providers, including hospitals. The timeframe for overpayment recovery efforts will be limited to two years, and a health plan must now provide 30 days written notice to a provider before beginning recovery efforts other than recoveries for duplicate payments.
  • Electronic claims must be paid in 30 days, rather than 45 days.
  • Plans will have one business day to make a determination of coverage for post-hospital services, including home health care services, following an inpatient admission.