Creates mental health parity for purposes of health insurance coverage; requires that adults and children with biologically based mental illnesses receive the same health care coverage benefits as those provided for any other physical ailments; requires the superintendent of insurance to cause a study to be performed to analyze the effect of requiring mental health care parity.
STATE OF NEW YORK
________________________________________________________________________
S. 8482 A. 12080
SENATE - ASSEMBLY
June 23, 2006
___________
IN SENATE -- Introduced by Sens. LIBOUS, MORAHAN, SPANO, BRUNO, FARLEY,
ALESI, BALBONI, BONACIC, DeFRANCISCO, FLANAGAN, FUSCHILLO, GOLDEN,
HANNON, JOHNSON, LARKIN, LAVALLE, LEIBELL, LITTLE, MALTESE, MARCELLI-
NO, MARCHI, MAZIARZ, NOZZOLIO, PADAVAN, RATH, ROBACH, SALAND, SKELOS,
TRUNZO, VOLKER, WINNER, WRIGHT, YOUNG -- read twice and ordered print-
ed, and when printed to be committed to the Committee on Rules
IN ASSEMBLY -- Introduced by COMMITTEE ON RULES -- (at request of M. of
A. Tonko, P. Rivera, Grannis, Gottfried, Brennan, Jacobs, Clark, Hoyt,
Gunther, Cahill, Alessi, Aubry, Benjamin, Bing, Boyland, Bradley,
Canestrari, A. Cohen, Colton, Cook, Cusick, Cymbrowitz, DiNapoli,
Dinowitz, Eddington, Englebright, Galef, Gianaris, Glick, Green,
Greene, Hikind, Koon, Lafayette, Lavelle, Lifton, Lupardo, McEneny,
Millman, O'Donnell, Ortiz, Paulin, Peoples, Perry, Pheffer, Powell,
J. Rivera, Schroeder, Sweeney, Towns, Weinstein, Weisenberg) -- read
once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to enacting "Timothy's
law"; and providing for the repeal of such provisions upon expiration
thereof
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Legislative finding and intent. The legislature hereby
2 declares that health insurance policies and health maintenance organiza-
3 tion contracts have not provided comparable coverage for adults and
4 children with biologically based mental illness or serious emotional
5 disturbance disorders affecting children under the same terms and condi-
6 tions as provided for medical treatment for physical illnesses.
7 Although federal law has prohibited the imposition of lower annual and
8 lifetime dollar limits by certain plans on mental health coverage, it is
9 the intent of this legislation to strengthen and enhance those
10 protections, and to ensure that mental health coverage is provided by
11 insurers and health maintenance organizations, and is provided on terms
12 comparable to other health care and medical services. Nothing in this
13 act is intended to limit or restrict the right of health maintenance
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD17628-02-6
S. 8482 2 A. 12080
1 organizations and health insurers to require that all services covered
2 by them satisfy reasonable and appropriate utilization review require-
3 ments, in accordance with their contracts, and applicable laws and regu-
4 lations, provided that such utilization review requirements are applied
5 in a consistent fashion to all services covered by such contracts.
6 § 2. Short title. This act shall be known and may be cited as
7 "Timothy's law".
8 § 3. Paragraph 5 of subsection (1) of section 3221 of the insurance
9 law, clause (ii) of subparagraph (A) as amended by chapter 555 of the
10 laws of 1993, subparagraph (B) as amended by chapter 21 of the laws of
11 1990, is amended to read as follows:
12 (5) (A) Every insurer delivering a group or school blanket policy or
13 issuing a group or school blanket policy for delivery, in this state,
14 which provides coverage for inpatient hospital care [must make avail-
15 able, and if requested by policyholder] shall provide, as part of such
16 policy, broad based coverage for the diagnosis and treatment of mental,
17 nervous or emotional disorders or ailments, however defined in such
18 policy, at least equal to the [following] coverage provided for other
19 health conditions and shall include:
20 (i) [with respect to] benefits [based upon confinement as an] for
21 inpatient care in a hospital as defined by subdivision ten of section
22 1.03 of the mental hygiene law, such benefits may be limited to not less
23 than thirty days of active treatment in any calendar year[;].
24 (ii) [with respect to] benefits for outpatient care provided in a
25 facility issued an operating certificate by the commissioner of mental
26 [hygiene] health pursuant to the provisions of article thirty-one of the
27 mental hygiene law, or in a facility operated by the [department] office
28 of mental [hygiene] health, or by a psychiatrist or psychologist
29 licensed to practice in this state or a professional corporation or
30 university faculty practice corporation thereof, such benefits may be
31 limited to not less than [seven hundred dollars] twenty days of active
32 treatment in any calendar year.
33 [(B) Such coverage shall be made available at the inception of all new
34 policies and with respect to all other policies and at any anniversary
35 date of the policy subject to evidence of insurability. Written notice
36 of the availability of such coverage shall be delivered to the policy-
37 holder prior to inception of such group policy and annually thereafter,
38 except that this notice shall not be required where a policy covers two
39 hundred or more employees or where the benefit structure was the subject
40 of collective bargaining affecting persons who are employed in more than
41 one state.
42 (C)] (iii) Such coverage may be subject to annual deductibles and
43 coinsurance as may be deemed appropriate by the superintendent[. Such
44 deductibles and coinsurance may] and shall be consistent with those
45 imposed on other benefits within a given policy.
46 [(D)] (iv) In this paragraph, "active treatment" means treatment
47 furnished in conjunction with inpatient confinement for mental, nervous
48 or emotional disorders or ailments that meet standards prescribed pursu-
49 ant to the regulations of the commissioner of mental [hygiene] health.
50 (B) (i) Every insurer delivering a group or school blanket policy or
51 issuing a group or school blanket policy for delivery, in this state,
52 which provides coverage for inpatient hospital care shall provide cover-
53 age comparable to medical coverage provided under the policy for adults
54 and children with biologically based mental illness. Such group poli-
55 cies issued or delivered in this state shall also provide such compara-
56 ble coverage for children with serious emotional disturbances. Such
S. 8482 3 A. 12080
1 coverage shall be provided under the terms and conditions otherwise
2 applicable under the policy, including network limitations or vari-
3 ations, exclusions, co-pays, coinsurance, deductibles or other specific
4 cost sharing mechanisms. Provided further, where a policy provides both
5 in-network and out-of-network benefits, the out-of-network benefits may
6 have different coinsurance, co-pays, or deductibles, than the in-network
7 benefits, regardless of whether the policy is written under one license
8 or two licenses.
9 (ii) For purposes of this paragraph, the term "biologically based
10 mental illness" means a mental, nervous, or emotional condition that is
11 caused by a biological disorder of the brain and results in a clinically
12 significant, psychological syndrome or pattern that substantially limits
13 the functioning of the person with the illness. Such biologically based
14 mental illnesses are defined as schizophrenia/psychotic disorders, major
15 depression, bipolar disorder, delusional disorders, panic disorder,
16 obsessive compulsive disorder, bulimia, and anorexia.
17 (C) For purposes of this subsection, the term "children with serious
18 emotional disturbances" means persons under the age of eighteen years
19 who have diagnoses of attention deficit disorders, disruptive behavior
20 disorders, or pervasive development disorders, and where there are one
21 or more of the following:
22 (i) serious suicidal symptoms or other life-threatening self-destruc-
23 tive behaviors;
24 (ii) significant psychotic symptoms (hallucinations, delusion, bizarre
25 behaviors);
26 (iii) behavior caused by emotional disturbances that placed the child
27 at risk of causing personal injury or significant property damage; or
28 (iv) behavior caused by emotional disturbances that placed the child
29 at substantial risk of removal from the household.
30 (D) The provisions of subparagraph (B) of this paragraph shall not
31 apply to any group purchaser with fifty or fewer employees that is a
32 policyholder of a policy that is subject to the provisions of this
33 section; provided however that an insurer must make available, and if
34 requested by such group purchaser, provide the coverage as specified in
35 subparagraph (B) of this paragraph; and provided further however that
36 the superintendent shall develop and implement a methodology to fully
37 cover the cost to any such group purchaser for providing the coverage
38 required in subparagraph (A) of this paragraph. Such methodology shall
39 be financed from funds from the General Fund that shall be made avail-
40 able to the superintendent for such purpose.
41 (E) (i) Nothing in this paragraph shall be construed to prevent the
42 medical management or utilization review of mental health benefits,
43 including the use of prospective, concurrent or retrospective utiliza-
44 tion review, preauthorization, and appropriateness criteria as to the
45 level and intensity of treatment applicable to behavioral health.
46 (ii) Nothing in this paragraph shall be construed to prevent a policy
47 from providing services through a network of participating providers who
48 shall meet certain requirements for participation, including provider
49 credentialing.
50 (iii) Nothing in this paragraph shall be construed to require a policy
51 (I) to cover mental health benefits or services for individuals who are
52 presently incarcerated, confined or committed to a local correctional
53 facility or a prison, or a custodial facility for youth operated by the
54 office of children and family services or (II) to cover services solely
55 because such services are ordered by a court.
S. 8482 4 A. 12080
1 (iv) Nothing in this paragraph shall be deemed to require a policy to
2 cover benefits or services deemed cosmetic in nature on the grounds that
3 changing or improving an individual's appearance is justified by the
4 individual's mental health needs.
5 § 4. Subsection (g) of section 4303 of the insurance law, as amended
6 by chapter 98 of the laws of 1988, paragraph 2 as amended by chapter 21
7 of the laws of 1990, is amended to read as follows:
8 (g) (1) A hospital service corporation or a health service corporation
9 which provides coverage for inpatient hospital care [must make available
10 and, if requested by all persons holding individual contracts in a
11 group, whose premiums are paid by a remitting agent or by the contract
12 holder in the case of a group contract issued pursuant to section four
13 thousand three hundred five of this article,] shall provide as part of
14 its contract, broad based coverage for the diagnosis and treatment of
15 mental, nervous or emotional disorders or ailments, however defined in
16 such contract, at least equal to the [following] coverage provided for
17 other health conditions and shall include:
18 (A) [with respect to] benefits [based upon confinement as an] for
19 in-patient care in a hospital as defined by subdivision ten of section
20 1.03 of the mental hygiene law, such benefits may be limited to not less
21 than thirty days of active treatment in any calendar year[;].
22 (B) [with respect to] benefits for out-patient care provided in a
23 facility issued an operating certificate by the commissioner of mental
24 [hygiene] health pursuant to the provisions of article thirty-one of the
25 mental hygiene law or in a facility operated by the [department] office
26 of mental [hygiene] health such benefits may be limited to not less than
27 [seven hundred dollars] twenty days of active treatment in any calendar
28 year.
29 [(2)] (C) Such coverage shall be [made available] provided at the
30 inception of all new contracts and, with respect to all other contracts,
31 at any anniversary date [subject to evidence of insurability]. Such
32 coverage may be subject to annual deductibles and coinsurance as may be
33 deemed appropriate by the superintendent[. Such deductibles and coinsu-
34 rance may] and shall be consistent with those imposed on other benefits
35 within a given contract. For the purpose of this subsection, "active
36 treatment" means treatment furnished in conjunction with in-patient
37 confinement for mental, nervous or emotional disorders or ailments that
38 meet such standards as shall be prescribed pursuant to the regulations
39 of the commissioner of mental [hygiene] health. [If the group remit-
40 tance group or contract holder in the case of a group contract also has
41 coverage from the same health service corporation or from a medical
42 expense indemnity corporation or another health service corporation for
43 physicians' services, the health service corporation shall not provide
44 the coverage under this subsection unless the group remittance group or
45 contract holder also obtains the coverage provided under subsection (h)
46 of this section.] In the event the group remittance group or contract
47 holder [obtains the] is provided coverage under this subsection and
48 under paragraph one of subsection (h) of this section from the same
49 health service corporation, or under a contract which is jointly under-
50 written by two health service corporations or by a health service corpo-
51 ration and a medical expense indemnity corporation, the aggregate of the
52 benefits for outpatient care obtained under subparagraph (B) of this
53 paragraph [one of this subsection] and paragraph one of subsection (h)
54 of this section may be limited to not less than [seven hundred dollars]
55 twenty days of active treatment in any calendar year. [Written notice
56 of the availability of such coverage shall be delivered to the group
S. 8482 5 A. 12080
1 remitting agent or group contract holder prior to inception of such
2 contract and annually thereafter, except that this notice shall not be
3 required where a policy covers two hundred or more employees or where
4 the benefit structure was the subject of collective bargaining affecting
5 persons who are employed in more than one state.]
6 (2) (A) A hospital service corporation or a health service corporation
7 which provides coverage for inpatient hospital care shall provide cover-
8 age, comparable to its medical care coverage, for adults and children
9 with biologically based mental illness. Such hospital service corpo-
10 ration or health service corporation shall also provide such comparable
11 coverage for children with serious emotional disturbances. Such cover-
12 age shall be provided under the terms and conditions otherwise applica-
13 ble under the contract, including network limitations or variations,
14 exclusions, co-pays, coinsurance, deductibles or other specific cost
15 sharing mechanisms. Provided further, where a contract provides both
16 in-network and out-of-network benefits, the out-of-network benefits may
17 have different coinsurance, co-pays, or deductibles, than the in-network
18 benefits, regardless of whether the contract is written under one
19 license or two licenses.
20 (B) For purposes of this subsection, the term "biologically based
21 mental illness" means a mental, nervous, or emotional condition that is
22 caused by a biological disorder of the brain and results in a clinically
23 significant, psychological syndrome or pattern that substantially limits
24 the functioning of the person with the illness. Such biologically based
25 mental illnesses are defined as schizophrenia/psychotic disorders, major
26 depression, bipolar disorder, delusional disorders, panic disorder,
27 obsessive compulsive disorders, anorexia, and bulimia.
28 (3) For purposes of this subsection, the term "children with serious
29 emotional disturbances" means persons under the age of eighteen years
30 who have diagnoses of attention deficit disorders, disruptive behavior
31 disorders, or pervasive development disorders, and where there are one
32 or more of the following:
33 (A) serious suicidal symptoms or other life-threatening self-destruc-
34 tive behaviors;
35 (B) significant psychotic symptoms (hallucinations, delusion, bizarre
36 behaviors);
37 (C) behavior caused by emotional disturbances that placed the child at
38 risk of causing personal injury or significant property damage; or
39 (D) behavior caused by emotional disturbances that placed the child at
40 substantial risk of removal from the household.
41 (4) The provisions of paragraph two of this subsection shall not apply
42 to any group contract holder with fifty or fewer employees who is a
43 contract holder of a policy that is subject to the provisions of this
44 section; provided however that a hospital service corporation or health
45 service corporation must make available, and if requested by such group
46 contract holder provide the coverage as specified in paragraph two of
47 this subsection; and provided further however that the superintendent
48 shall develop and implement a methodology to fully cover the cost to any
49 such group contract holder for providing the coverage required in para-
50 graph one of this subsection. Such methodology shall be financed from
51 moneys from the General Fund that shall be made available to the super-
52 intendent for such purpose.
53 (5)(A) Nothing in this subsection shall be construed to prevent the
54 medical management or utilization review of mental health benefits,
55 including the use of prospective, concurrent or retrospective utiliza-
S. 8482 6 A. 12080
1 tion review, preauthorization, and appropriateness criteria as to the
2 level and intensity of treatment applicable to behavioral health.
3 (B) Nothing in this subsection shall be construed to prevent a
4 contract from providing services through a network of participating
5 providers who shall meet certain requirements for participation, includ-
6 ing provider credentialing.
7 (C) Nothing in this subsection shall be construed to require a
8 contract (I) to cover mental health benefits or services for individuals
9 who are presently incarcerated, confined or committed to a local correc-
10 tional facility or a prison, or a custodial facility for youth operated
11 by the office of children and family services or (II) to cover services
12 solely because such services are ordered by a court.
13 (D) Nothing in this subsection shall be deemed to require a contract
14 to cover benefits or services deemed cosmetic in nature on the grounds
15 that changing or improving an individual's appearance is justified by
16 the individual's mental health needs.
17 § 5. Subsection (h) of section 4303 of the insurance law, as amended
18 by chapter 420 of the laws of 2002, is amended to read as follows:
19 (h) (1) A medical expense indemnity corporation or a health service
20 corporation which provides coverage for physician services [must make
21 available and, if requested by all persons holding individual contracts
22 in a group, whose premiums are paid by a remitting agent or by the
23 contract holder in the case of a group contract issued pursuant to
24 section four thousand three hundred five of this article,] shall provide
25 as part of its contract, broad based coverage for the diagnosis and
26 treatment of mental, nervous or emotional disorders or ailments, however
27 defined in such contract, at least equal to the [following] coverage
28 provided for other health conditions and shall include: [with respect
29 to] benefits for outpatient care provided by a psychiatrist or psychol-
30 ogist licensed to practice in this state, a licensed clinical social
31 worker who meets the requirements of subsection (n) of this section, or
32 a professional corporation or university faculty practice corporation
33 thereof, such benefits may be limited to not less than [seven hundred
34 dollars] twenty days of active treatment in any calendar year. Such
35 coverage shall be [made available] provided at the inception of all new
36 contracts and with respect to all other contracts, at any anniversary
37 date [subject to evidence of insurability]. Such coverage may be subject
38 to annual deductibles and coinsurance as may be deemed appropriate by
39 the superintendent[. Such deductibles and coinsurance may] and shall be
40 consistent with those imposed on other benefits within a given contract.
41 [If the group remittance group or contract holder in the case of a group
42 contract also has coverage from the same health service corporation or
43 from another health service corporation for in-patient hospital care,
44 the medical expense indemnity corporation or the health service corpo-
45 ration shall not provide the coverage under this subsection unless the
46 group remittance group or contract holder also obtains the coverage
47 provided under subparagraph (B) of paragraph one of subsection (g) of
48 this section.] In the event the group remittance group or contract hold-
49 er [obtains the] is provided coverage provided under this [subsection]
50 paragraph and under subparagraph (B) of paragraph one of subsection (g)
51 of this section from the same health service corporation, or under a
52 contract which is jointly underwritten by two health service corpo-
53 rations or by a health service corporation and a medical expense indem-
54 nity corporation, the aggregate of the benefits for out-patient care
55 obtained under subparagraph (B) of paragraph one of subsection (g) of
56 this section and this [subsection] paragraph may be limited to not less
S. 8482 7 A. 12080
1 than [seven hundred dollars] twenty days of active treatment in any
2 calendar year. [Written notice of the availability of such coverage
3 shall be delivered to the group remitting agent or group contract holder
4 prior to inception of such contract and annually thereafter, except that
5 this notice shall not be required where a policy covers two hundred or
6 more employees or where the benefit structure was the subject of collec-
7 tive bargaining affecting persons who are employed in more than one
8 state.]
9 (2) (A) A medical expense indemnity corporation or a health service
10 corporation which provides coverage for physician services shall provide
11 coverage, comparable to its medical care coverage, for adults and chil-
12 dren with biologically based mental illness. Such medical expense
13 indemnity corporation or health service corporation shall also provide
14 such comparable coverage for children with serious emotional disturb-
15 ances. Such coverage shall be provided under the terms and conditions
16 otherwise applicable under the contract, including network limitations
17 or variations, exclusions, co-pays, coinsurance, deductibles or other
18 specific cost sharing mechanisms. Provided further, where a contract
19 provides both in-network and out-of-network benefits, the out-of-network
20 benefits may have different coinsurance, co-pays, or deductibles, than
21 the in-network benefits, regardless of whether the contract is written
22 under one license or two licenses.
23 (B) For purposes of this subsection, the term "biologically based
24 mental illness" means a mental, nervous, or emotional condition that is
25 caused by a biological disorder of the brain and results in a clinically
26 significant, psychological syndrome or pattern that substantially limits
27 the functioning of the person with the illness. Such biologically
28 based mental illnesses are defined as schizophrenia/psychotic disorders,
29 major depression, bipolar disorder, delusional disorders, panic disor-
30 der, obsessive compulsive disorder, anorexia, and bulimia.
31 (3) For purposes of this subsection, the term "children with serious
32 emotional disturbances" means persons under the age of eighteen years
33 who have diagnoses of attention deficit disorders, disruptive behavior
34 disorders, or pervasive development disorders, and where there are one
35 or more of the following:
36 (A) serious suicidal symptoms or other life-threatening self-destruc-
37 tive behaviors;
38 (B) significant psychotic symptoms (hallucinations, delusion, bizarre
39 behaviors);
40 (C) behavior caused by emotional disturbances that placed the child at
41 risk of causing personal injury or significant property damage; or
42 (D) behavior caused by emotional disturbances that placed the child at
43 substantial risk of removal from the household.
44 (4) The provisions of paragraph two of this subsection shall not apply
45 to any group contract holder with fifty or fewer employees who is a
46 contract holder of a contract that is subject to the provisions of this
47 section; provided, however, that a medical expense indemnity corporation
48 or health service corporation must make available, and if requested by
49 such group contract holder, provide the coverage as specified in para-
50 graph two of this subsection; and provided further however that the
51 superintendent shall develop and implement a methodology to fully cover
52 the cost to any such group contract holder for providing the coverage
53 required in paragraph one of this subsection. Such methodology shall be
54 financed from moneys from the General Fund that shall be made available
55 to the superintendent for such purpose.
S. 8482 8 A. 12080
1 (5)(A) Nothing in this subsection shall be construed to prevent the
2 medical management or utilization review of mental health benefits,
3 including the use of prospective, concurrent or retrospective utiliza-
4 tion review, preauthorization, and appropriateness criteria as to the
5 level and intensity of treatment applicable to behavioral health.
6 (B) Nothing in this subsection shall be construed to prevent a
7 contract from providing services through a network of participating
8 providers who shall meet certain requirements for participation, includ-
9 ing provider credentialing.
10 (C) Nothing in this subsection shall be construed to require a
11 contract (I) to cover mental health benefits or services for individuals
12 who are presently incarcerated, confined or committed to a local correc-
13 tional facility or a prison, or a custodial facility for youth operated
14 by the office of children and family services or (II) to cover services
15 solely because such services are ordered by a court.
16 (D) Nothing in this subsection shall be deemed to require a contract
17 to cover benefits or services deemed cosmetic in nature on the grounds
18 that changing or improving an individual's appearance is justified by
19 the individual's mental health needs.
20 § 6. The superintendent of insurance shall monitor the implementation
21 of the coverage required pursuant to subparagraph (A) of paragraph 5 of
22 subsection (l) of section 3221, paragraph (1) of subsection (g) of
23 section 4303 and paragraph 1 of subsection (h) of section 4303 of the
24 insurance law, and take such action as may be necessary, to ensure that
25 insurers' contracts or policies do not contain an unreasonable defi-
26 nition of mental, nervous or other emotional disorders or ailments in
27 their contracts or policies. In determining whether such definition may
28 be unreasonable, the superintendent of insurance shall ensure that any
29 exclusions and limitations on covered benefits are consistent with bene-
30 fits provided to public officers and employees pursuant to article 11 of
31 the civil service law.
32 § 7. a. The superintendent of insurance, in consultation with the
33 office of mental health, shall cause a study to be performed on the
34 effectiveness of mental health parity. Such study shall include, but not
35 be limited to:
36 (i) a comprehensive analysis of the costs associated with providing
37 coverage pursuant to this act;
38 (ii) the number of policyholders and group contract holders which have
39 elected to purchase other mental health coverage required to be made
40 available pursuant to this act; and
41 (iii) a comparison of the type and number of illnesses for which
42 coverage has been provided during the study period.
43 b. The study shall encompass a two year period.
44 c. On or before April 1, 2009, the superintendent of insurance shall
45 deliver a copy of the findings of the study and any legislative recom-
46 mendations to the governor, the temporary president of the senate, the
47 speaker of the assembly, and the chairs of the insurance committees in
48 the senate and the assembly.
49 § 8. This act shall take effect on the first of January next succeed-
50 ing the date on which it shall have become a law and shall expire and be
51 deemed repealed December 31, 2009; and the provisions of this act shall
52 apply to policies and contracts issued, renewed, modified, altered or
53 amended on or after such effective date.
