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A03694 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         3694--A
 
                               2017-2018 Regular Sessions
 
                   IN ASSEMBLY
 
                                    January 30, 2017
                                       ___________
 
        Introduced  by M. of A. GUNTHER -- read once and referred to the Commit-
          tee on  Insurance  --  committee  discharged,  bill  amended,  ordered
          reprinted as amended and recommitted to said committee
 
        AN  ACT  to  amend  the  insurance  law, in relation to establishing the
          mental health and substance use disorder parity report act

          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section  1.  Short  title. This act shall be known and may be cited as
     2  the "mental health and substance use disorder parity report act".
     3    § 2. Subsection (a) of section 210 of the insurance law, as amended by
     4  chapter 579 of the laws of 1998, is amended to read as follows:
     5    (a) The superintendent shall annually publish on or  before  September
     6  first, nineteen hundred ninety-nine, and annually thereafter, a consumer
     7  guide  to  insurers providing managed care products, individual accident
     8  and health insurance or group or blanket accident and  health  insurance
     9  and  entities  licensed  pursuant  to  article  forty-four of the public
    10  health law providing comprehensive health service plans which  includes,
    11  in  detail, a ranking from best to worst based upon each company's claim
    12  processing or medical payments record during the preceding calendar year
    13  using criteria available to  the  department,  adjusted  for  volume  of
    14  coverage  provided.  Such ranking shall also take into consideration the
    15  corresponding total number or percentage of  claims  denied  which  were
    16  reversed  or  compromised  after  intervention by the department and the
    17  department of health, consumer complaints  to  the  department  and  the
    18  department  of  health, violations of section three thousand two hundred
    19  twenty-four-a of this chapter  and  other  pertinent  data  which  would
    20  permit  the department to objectively determine a company's performance.
    21  The department in publishing  such  consumer  guide  shall  publish  one
    22  state-wide  guide  or no more than five regional guides so as to facili-
    23  tate comparisons among individual insurers and entities within a service
    24  market area. Such rankings shall be printed in a format which ranks  all
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02509-08-7

        A. 3694--A                          2
 
     1  health  insurers  and  all entities certified pursuant to article forty-
     2  four of the public health law in one combined list. The  consumer  guide
     3  on  or before September first, two thousand eighteen and annually there-
     4  after,  shall include a mental health parity report and a substance uses
     5  disorder parity report based upon each company's compliance with  mental
     6  health  parity  and  substance  use  disorder  parity laws based on each
     7  company's record during  the  preceding  calendar  year  using  criteria
     8  available  to the department, including, but not limited to, information
     9  required by this subsection and subsections (b), (c)  and  (d)  of  this
    10  section.  In  addition, notwithstanding such requirements and any law to
    11  the contrary, the data to be included in the mental health parity report
    12  and the substance use disorder parity report and collected by the super-
    13  intendent and the commissioner of health from insurers and health plans,
    14  for such purposes shall include:
    15    (1) Annual mental health parity  and  substance  use  disorder  parity
    16  compliance  reports  from  each insurer and health plan outlining how it
    17  complies with Timothy's law,  the  insurance  law  provisions  regarding
    18  substance  use  disorder and eating disorders and the Paul Wellstone and
    19  Pete Domenici mental health parity and addiction equity act of two thou-
    20  sand eight;
    21    (2) Rates of utilization review for mental health  and  substance  use
    22  disorder  claims  as  compared to medical and surgical claims, including
    23  rates of approval and denial, categorized by benefits provided under the
    24  following classifications, as required under 45  C.F.R.  §  146.136,  29
    25  C.F.R.  §  2590.712  and  26  C.F.R. § 54.9812-1.: inpatient in-network,
    26  inpatient out-of-network, outpatient in-network, outpatient  out-of-net-
    27  work, emergency care, and prescription drugs;
    28    (3)  The  number  of  prior  or  concurrent authorization requests for
    29  mental health services and for substance use disorder services  and  the
    30  number  of  denials for such requests, compared with the number of prior
    31  or concurrent authorization requests for medical and  surgical  services
    32  and  the  number  of  denials for such requests, categorized by the same
    33  classifications identified in paragraph two  of  this  subsection  which
    34  shall also include the rates of internal and external appeals, including
    35  rates  of  appeals upheld and overturned, specifically for mental health
    36  benefits and substance use disorder benefits;
    37    (4) The number of  prior  or  concurrent  authorization  requests  for
    38  mental  health services and substance use disorder services that went to
    39  clinical peer review as a result of a disagreement between  the  service
    40  provider  and  the  insurer  or  health plan and the number that went to
    41  clinical peer review for medical and surgical  services  categorized  in
    42  the same manner as provided in paragraph two of this subsection;
    43    (5) The list of services that have a prior or concurrent authorization
    44  requirement  based on a numerical threshold defined by a specific number
    45  of visits or days of care for  mental  health  services,  substance  use
    46  disorder  services  and medical and surgical services and identification
    47  of the threshold requirements;
    48    (6) The list of covered medications for the treatment of  a  substance
    49  use disorder on the prescription drug list of the insurer or health plan
    50  including  tier  placement,  authorization  requirements  and  all other
    51  utilization management requirements;
    52    (7) The  percentage  of  claims  paid  for  in-network  mental  health
    53  services  and  for substance use disorder services and the percentage of
    54  claims paid for in-network medical and surgical services;
    55    (8) The percentage of claims paid  for  out-of-network  mental  health
    56  services  and substance use disorder services compared with the percent-

        A. 3694--A                          3
 
     1  age of claims paid for other types of out-of-network medical and  surgi-
     2  cal services;
     3    (9)  The medical necessity criteria the insurer or health plan uses to
     4  make prior authorization  or  continuing  care  and  discharge  determi-
     5  nations,  which  in conjunction must be conspicuously posted for policy-
     6  holders and providers to be able to review without making a  request  on
     7  the insurer's or the health plan's website and be made available in hard
     8  copy upon request;
     9    (10)  The number of behavioral health advocates, pursuant to an agree-
    10  ment with the office of the attorney general if applicable, or staff  on
    11  hand  to  assist  policyholders  with  benefits  for  mental  health  or
    12  substance use disorder;
    13    (11) The network adequacy of insurers and health plans, which in addi-
    14  tion to the requirements of subsection (a) of section three thousand two
    15  hundred forty-one of this chapter and subsection (c)  of  this  section,
    16  shall  consist of verifying the mental health and substance use disorder
    17  providers listed in an insurer's or health plan's provider directory  as
    18  in network. Such verification shall be provided by the insurer or health
    19  plan, on a semi-annual basis, by providing its list of in-network mental
    20  health  and  substance  use  disorder providers and the number of claims
    21  each provider has submitted within the past six months. The  list  shall
    22  include  the  name,  address  and  telephone number of all participating
    23  in-network providers.  For providers that have had no claims in the past
    24  six months, the insurer or health plan must provide an attestation  that
    25  such  provider  is  still  part  of the network and that the provider is
    26  accepting new patients. For qualified health plans offered on  New  York
    27  state  of  health,  the  department  of  health shall review the network
    28  adequacy to ensure it is consistent  with  45  CFR  §  156.230  and  the
    29  department  of health's managed care network adequacy standard including
    30  verification of the mental health and substance use  disorder  providers
    31  listed  in  a  qualified health plan's provider directory as in-network.
    32  Such verification shall be provided by a qualified  health  plan,  on  a
    33  semi-annual basis, by providing its list of in-network mental health and
    34  substance  use disorder providers and the number of claims each provider
    35  has submitted within the past six months. The  list  shall  include  the
    36  name,  address  and telephone number of all participating providers. For
    37  providers that have no claims in the  past  six  months,  the  qualified
    38  health plan must provide an attestation that such provider is still part
    39  of the network and that the provider is accepting new patients;
    40    (12)  The number of mental health and substance use disorder providers
    41  who have left or been removed from the provider network in the past  six
    42  months and the reason that they have left or been removed; and
    43    (13)  Any  other data or metric the superintendent or the commissioner
    44  of health deems is necessary to measure compliance  with  mental  health
    45  parity and substance use disorder parity.
    46    §  3.  Paragraph  2  of subsection (c) of section 210 of the insurance
    47  law, as added by chapter 579 of the laws of 1998, is amended to read  as
    48  follows:
    49    (2) the percentage of primary care physicians who remained participat-
    50  ing  providers,  provided  however,  that  such percentage shall exclude
    51  voluntary terminations due to physician retirement, relocation or  other
    52  similar  reasons,  and  the  percentage  of mental health professionals,
    53  defined as physicians who are licensed pursuant to article  one  hundred
    54  thirty-one  of the education law who are diplomats of the American board
    55  of psychiatry and neurology or are eligible  to  be  certified  by  that
    56  board,  or  are certified by the American osteopathic board of neurology

        A. 3694--A                          4
 
     1  and psychiatry or are eligible to be certified by that board,  a  social
     2  worker licensed pursuant to article one hundred fifty-four of the educa-
     3  tion  law  or  a  psychologist  licensed pursuant to article one hundred
     4  fifty-three  of the education law, who remained as participating provid-
     5  ers and the number of claims each type of mental health professional has
     6  submitted in the last twelve months and  the  number  of  mental  health
     7  professionals,  if  any,  who have not had any claims in the last twelve
     8  months;
     9    § 4. Subsection (d) of section 210 of the insurance law, as  added  by
    10  chapter 579 of the laws of 1998, is amended to read as follows:
    11    (d)  Health insurers and entities certified pursuant to article forty-
    12  four of the public health law shall provide annually to the  superinten-
    13  dent  and  the  commissioner  of  health, and the commissioner of health
    14  shall provide to the superintendent, all of  the  information  necessary
    15  for  the  superintendent to produce the annual consumer guide, including
    16  the mental health parity report and the substance  use  disorder  parity
    17  report.    In  compiling  the guide, the superintendent shall make every
    18  effort to ensure that the information is presented in  a  clear,  under-
    19  standable  fashion which facilitates comparisons among individual insur-
    20  ers and entities, and in a format  which  lends  itself  to  the  widest
    21  possible  distribution  to  consumers.  The  superintendent shall either
    22  include the information from the annual consumer guide in  the  consumer
    23  shopping guide required by subsection (a) of section four thousand three
    24  hundred  twenty-three  of this chapter or combine the two guides as long
    25  as consumers in the individual market are provided with the  information
    26  required  by subsection (a) of section four thousand three hundred twen-
    27  ty-three of this chapter.
    28    § 5. This act shall take effect on the sixtieth  day  after  it  shall
    29  have  become a law, provided, however, effective immediately, the amend-
    30  ment and/or repeal of any rule or regulation necessary for the implemen-
    31  tation of this act on its effective date are authorized and directed  to
    32  be made and completed on or before such effective date.
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