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A03694 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         3694--B
 
                               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 -- recommitted
          to the Committee on Insurance in accordance with Assembly Rule 3, sec.
          2 -- 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
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02509-10-8

        A. 3694--B                          2
 
     1  state-wide  guide  or no more than five regional guides so as to facili-
     2  tate comparisons among individual insurers and entities within a service
     3  market area. Such rankings shall be printed in a format which ranks  all
     4  health  insurers  and  all entities certified pursuant to article forty-
     5  four of the public health law in one combined list. The  consumer  guide
     6  on  or before September first, two thousand nineteen and annually there-
     7  after, shall include a mental health parity report and a substance  uses
     8  disorder  parity report based upon each company's compliance with mental
     9  health parity and substance use  disorder  parity  laws  based  on  each
    10  company's  record  during  the  preceding  calendar  year using criteria
    11  available to the department, including, but not limited to,  information
    12  required  by  this  subsection  and subsections (b), (c) and (d) of this
    13  section. In addition, notwithstanding such requirements and any  law  to
    14  the contrary, the data to be included in the mental health parity report
    15  and the substance use disorder parity report and collected by the super-
    16  intendent and the commissioner of health from insurers and health plans,
    17  for such purposes shall include:
    18    (1)  Annual  mental  health  parity  and substance use disorder parity
    19  compliance reports from each insurer and health plan  outlining  how  it
    20  complies  with  Timothy's  law,  the  insurance law provisions regarding
    21  substance use disorder and eating disorders and the Paul  Wellstone  and
    22  Pete Domenici mental health parity and addiction equity act of two thou-
    23  sand eight;
    24    (2)  Rates  of  utilization review for mental health and substance use
    25  disorder claims as compared to medical and  surgical  claims,  including
    26  rates of approval and denial, categorized by benefits provided under the
    27  following  classifications,  as  required  under 45 C.F.R. § 146.136, 29
    28  C.F.R. § 2590.712 and 26  C.F.R.  §  54.9812-1.:  inpatient  in-network,
    29  inpatient  out-of-network, outpatient in-network, outpatient out-of-net-
    30  work, emergency care, and prescription drugs;
    31    (3) The number of  prior  or  concurrent  authorization  requests  for
    32  mental  health  services and for substance use disorder services and the
    33  number of denials for such requests, compared with the number  of  prior
    34  or  concurrent  authorization requests for medical and surgical services
    35  and the number of denials for such requests,  categorized  by  the  same
    36  classifications  identified  in  paragraph  two of this subsection which
    37  shall also include the rates of internal and external appeals, including
    38  rates of appeals upheld and overturned, specifically for  mental  health
    39  benefits and substance use disorder benefits;
    40    (4)  The  number  of  prior  or  concurrent authorization requests for
    41  mental health services and substance use disorder services that went  to
    42  clinical  peer  review as a result of a disagreement between the service
    43  provider and the insurer or health plan and  the  number  that  went  to
    44  clinical  peer  review  for medical and surgical services categorized in
    45  the same manner as provided in paragraph two of this subsection;
    46    (5) The list of services that have a prior or concurrent authorization
    47  requirement based on a numerical threshold defined by a specific  number
    48  of  visits  or  days  of  care for mental health services, substance use
    49  disorder services and medical and surgical services  and  identification
    50  of the threshold requirements;
    51    (6)  The  list of covered medications for the treatment of a substance
    52  use disorder on the prescription drug list of the insurer or health plan
    53  including tier  placement,  authorization  requirements  and  all  other
    54  utilization management requirements;

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

        A. 3694--B                          4

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