Written by a parent, not a doctor. Nothing here is medical advice.

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New York program

Approval deadlines, step-therapy exceptions and continuity of care

New York sets deadlines for some health-plan approval requests and exceptions to trying another drug first.

What it is

New York sets deadlines for some health-plan approval requests and exceptions to trying another drug first.

Waiting for a plan's answer can delay treatment. New York law sets decision clocks for covered plans and allows exceptions to step therapy. The kind of request and the plan's legal status determine which clock applies.

Eligibility rules
  • These rights apply to covered New York-regulated insurers and HMOs. The step-therapy rule also expressly includes Article 47 municipal cooperative plans.
  • Private self-funded ERISA plans generally fall outside these state insurance mandates. Medicaid fee-for-service and Medicare have different step-therapy rules. NYSHIP preserves state mandates and appeals; Article 47 municipal cooperative plans are expressly addressed by the state step-therapy guidance.
  • An incomplete standard request triggers a request for information within three business days. You have 45 calendar days to respond.
What you get
  • A 72-hour urgent or three-business-day standard decision clock for covered approval requests.
  • A route to ask for an exception to trying another drug first.
  • Up to 90 days of continued treatment after a doctor leaves the network, when conditions are met.
What the help includes
  • Step-therapy overrides have 72-hour standard and 24-hour urgent clocks when supporting rationale is supplied.
  • Reasons include likely harm, expected ineffectiveness, a failed drug or drug class, or stability on the current medicine, subject to the generic exception.
  • Adherence, other health conditions and functional harm can also support an exception.
  • A departing clinician’s transition period can last up to 90 days if the clinician accepts the prior rate and other required terms. A new member’s transition is a different pathway. Public Health Law §4403(6)(f) has current 60-day conditions and a 90-day amendment effective January 1, 2027. Your plan can identify which product, transition category and operative rule apply.
If you decide to apply
  1. Ask the clinic to identify the applicable deadline and document when the plan received a complete request.
  2. For a step-therapy exception, ask the doctor to explain why the required drug is unsuitable.
  3. If you want to challenge a delay or denial, ask the hospital's insurance specialist to review the plan response with you.

Health-plan appeals office; New York Department of Financial Services · Official page ↗

After you ask
  • After missing information arrives, the standard decision is due within three business days, or 15 calendar days after the response period ends.
  • The internal appeal and eligible external appeal are distinct routes after a denial.
Good to know

A missed deadline automatically grants the initial step-therapy override in covered cases. That rule does not apply to every approval request or appeal.

Other details
  • The automatic-approval rule is limited to an initial step-therapy override. It does not guarantee the outcome of a later appeal.
  • The plan and type of request determine the clock. For covered New York utilization review, urgent requests generally have a 72-hour limit; standard pre-service requests generally have three business days once the necessary information is received, with separate deadlines for missing information. An initial step-therapy override uses 72 hours, or 24 hours when urgent, after the supporting rationale is supplied; a missed deadline can grant that override, not every delayed request. NYSHIP has state-law mandate and appeal protections; another teacher or municipal plan needs its own legal status checked. A proposed gold-card bill is not proof of an exemption in force.
Official sources
Ask your social worker

“Which approval deadline applies to our child's request, and would an exception to trying another drug be appropriate? What are the limits, and could you help the clinic document it?”

Why I’m asking: We want to avoid preventable treatment delays and understand what the plan must answer.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask the clinic to name the deadline, keep the dates, and call DFS when a deadline is missed.

Your social worker

The clinic's insurance navigator submits complete requests and tracks the deadlines.

The care team

Writes the step-therapy rationale (contraindication, ineffectiveness, prior failure, stability, best interest) and certifies urgency.

Who decides
The health plan decides within the deadlines; the state insurance regulator (the Department of Financial Services) enforces them for fully insured plans.
Ask the care team
“Can the request say "urgent, 72-hour determination" and, for the step-therapy override, cite the ground so the plan must answer within 72 hours (24 if urgent)?”

How to apply

First step: Ask the clinic to write "urgent, 72-hour determination" (or "3 business days") into each prior-approval request, and to send any step-therapy override with the doctor's rationale.

  1. Ask the clinic to write the clock into each prior-approval request.
  2. For a step-therapy demand, send the override request with the doctor's rationale and note the 72-hour (24-hour) deadline.
  3. If an oncologist leaves the network, ask the plan in writing for 90 days of continuity.

Official application / program page ↗

Where it starts: Ask the clinic to name the clock in every request; ask the plan in writing for the step-therapy override with the doctor's rationale; call DFS if the clock is missed.

What to gather

  • The plan's request and the date it was complete
  • The doctor's rationale for any override
  • Any network-change notice

How long: 72 hours urgent; 3 business days standard; 72 or 24 hours for a step-therapy override.

What a yes looks like

An approval letter within the deadline, or an override granted (including because the plan missed its deadline).

What a no looks like, and the next move

A denial: appeal inside the plan, then the DFS external appeal within four months. A missed deadline: call the state insurance regulator (DFS).

Watch out

  • The "deemed approved" rule is for the first step-therapy override request only, not for appeals or every prior-approval deadline.
  • Self-insured plans, Medicaid fee-for-service and Medicare are outside the step-therapy law. Whether state-employee and teacher plans are inside was not found.
  • No gold-card exemption exists in New York (a bill sits in committee). Continuity of care needs the provider to accept the old contracted rate.
  • NYSHIP’s direct benefits preserve specified mandates and appeals. An employer-funded public plan is not automatically outside those protections; ask whether the current Empire, teacher or municipal plan adopts them.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

Covered requests generally have a 72-hour urgent or three-business-day complete standard clock. Initial step-therapy overrides use 72 hours, or 24 urgent, after supporting rationale; the missed-deadline remedy applies to that override. A departing clinician’s transition can last up to 90 days if payment and other conditions are met. New-member transitions have separate rules and effective dates.

  • $72 — Urgent prior-approval decision
  • $3 — Standard pre-service decision (complete request)
  • $45 — Days you have to send requested information
  • $72 — Step-therapy override decision (with supporting rationale)
  • $24 — Urgent step-therapy override decision
  • $90 — Continued course of treatment after a provider leaves the network

Legal protection: Step-therapy override grounds: contraindication or likely harm; expected ineffectiveness; a prior unsuccessful trial of the drug or its class; stability on the current drug (AB-rated generic excepted); adherence, comorbidity or functional harm · A missed initial override deadline means the override is granted · Continuity at in-network cost sharing, with the provider accepting the prior contracted rate

What it costs the family: None.

The eligibility facts, as published

Plan type
HMOs and insurers subject to New York law (the ID card says fully insured); plans bought through NY State of Health
Step therapy scope
does not apply to self-insured plans, Medicaid fee-for-service or Medicare; expressly includes Article 47 municipal cooperative health benefit plans; policies issued or renewed after 2017-01-01
Public employee plans
per-right applicability to NYSHIP and teacher plans NOT FOUND
Gold card
no enacted exemption (S7470 referred to committee 2025-04-17)
Incomplete requests
the plan asks within 3 business days; 45 calendar days to respond; decision within 3 business days of receipt or 15 calendar days after the response period

Decisions this site cannot make: Utilization review determination · Step-therapy override determination

Expect friction on: Clinician must supply the rationale · Plan type decides reach

The trap: The deemed-approval rule applies only to the first step-therapy override request, not to appeals or every prior-approval deadline. No gold-card exemption has been enacted (a bill sits in committee).

Where I read this

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