External Appeal in New York; Are Recent Changes Enough?

By Hunter Raines, Albany Government Law Review

New York’s external appeal legislation, giving patients and health care providers a right to an external appeal of health plan adverse coverage determinations, has been invaluable in improving the patient’s access to care while protecting the provider’s right to adequate reimbursement for health care services.  However, changes enacted in July 2011 measurably impact the operation of this statutory creature, which merits examination and review of the process as it currently stands.[1]

In the early 1990s, the rising costs of health care inspired a new insurance model closely tied to the concept of strict care management.[2]  By strictly managing consumer options, health care costs were constrained.[3]  However, this model encumbered access to needed health care for many.[4]  New York’s Managed Care Reform Act, signed by Governor Pataki in 1996, provided new protection for New York consumers in the health insurance market.[5]  Since the passage of the act, consumers now have the right to obtain a description of services and procedures covered by their health plan, the right to an explanation of the patient’s financial responsibility for such procedures and services and the right to appeal adverse coverage determinations.[6]  These legislative protections are far reaching, applying to most health plans excluding those which are self-funded or otherwise subject to ERISA, which is beyond the scope of this article.[7] Continue reading “External Appeal in New York; Are Recent Changes Enough?”

“New York’s Last, Best Hope for Real Reform”: The Case for Convening a State Constitutional Convention

By Brian M. Kolb, New York State Assembly Republican Leader

In the lead article of the inaugural issue of the Albany Government Law Review’s New York Legislation book, Assembly Republican Leader Brian Kolb convincingly advocates for a “People’s Constitutional Convention.”   Mr. Kolb, the Assembly Minority Leader, argues that, since the last convention in 1967, the fiscal, governmental and confidence crises are reasons not to wait until 2017, the next time the question of convening a convention will automatically appear on the ballot.

Mr. Kolb created an online petition to call for a convention: Reform New York.  To date, nearly 2,500 have signed, at least virtually, the petition to support a People’s Convention to Reform New York.

The term “reform” has reached remora-like status in Albany, attached to nearly anything, and in cases that may result in only marginal improvement.  As Mr. Kolb writes, the People’s convention is needed to address far-reaching, institutional change:

State government’s dysfunction, corruption, and fiscal irresponsibility are still the ultimate trump card that can mobilize public opinion and serve as an urgent call to action. As symptoms of these “cancers” on government continue to manifest themselves in the form of chronic unemployment, late state budgets, multi-billion dollar deficits and debt, some of the nation’s highest property, business, and income taxes, the “case” for convening a constitutional convention will be self-evident, extremely powerful, and, in my opinion, open and shut. The fact that state government still lacks a statewide succession plan for state offices, an independent Legislative Redistricting Commission, term limits for legislative leaders and legislators, initiative and referendum, . . . will continue inspiring calls for reforming the broken institution of state government.

Click here to view the article by Assembly Republican Leader Kolb.