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A07704 Summary:

A07704 Actions:

A07704 Committee Votes:

Committee:INSURANCE   Chair:Cahill      
DATE:05/25/2021AYE/NAY:23/0  Action: Favorable refer to committee Codes        
Cahill
Aye
Blankenbush
Aye
Cook
Aye
Hawley
Aye
Pretlow
Aye
Byrne
Aye
Rivera
Aye
Schmitt
Aye
Cymbrowitz
Aye
Palmesano
Aye
Lavine
Aye
DiPietro
Aye
Steck
Aye
Gandolfo
Excused
Dilan
Aye
Hunter
Aye
Niou
Aye
Rosenthal
Aye
Stern
Aye
McDonald
Aye
Jacobson
Aye
Williams
Aye
Meeks
Aye
Forrest
Excused
Anderson
Aye

Committee:CODES   Chair:Dinowitz      
DATE:06/07/2021AYE/NAY:22/0  Action: Favorable refer to committee Ways and Means        
Dinowitz
Aye
Morinello
Aye
Pretlow
Aye
Giglio
Aye
Cook
Aye
Montesano
Aye
Cymbrowitz
Aye
Reilly
Aye
O'Donnell
Aye
Mikulin
Aye
Lavine
Aye
Tannousis
Aye
Perry
Aye
Abinanti
Aye
Weprin
Aye
Hevesi
Aye
Fahy
Aye
Seawright
Aye
Rosenthal
Aye
Walker
Aye
Vanel
Aye
Cruz
Aye

Committee:WAYS AND MEANS   Chair:Weinstein      
DATE:06/10/2021AYE/NAY:32/2  Action: Favorable refer to committee Rules        
Weinstein
Aye
Ra
Nay
Glick
Aye
Fitzpatrick
Aye
Nolan
Excused
Hawley
Aye
Pretlow
Aye
Montesano
Aye
Perry
Aye
Blankenbush
Aye
Colton
Aye
Norris
Aye
Cook
Aye
Brabenec
Aye
Cahill
Aye
Palmesano
Aye
Aubry
Aye
Byrne
Nay
Cusick
Aye
Ashby
Aye
Benedetto
Aye
Weprin
Aye
Rodriguez
Aye
Ramos
Aye
Braunstein
Aye
McDonald
Aye
Rozic
Aye
Dinowitz
Aye
Joyner
Aye
Magnarelli
Aye
Zebrowski
Aye
Bronson
Aye
Dilan
Aye
Seawright
Aye
Hyndman
Aye

Committee:RULES   Chair:Gottfried      
DATE:06/10/2021AYE/NAY:29/0  Action: Favorable         
Heastie
Excused
Barclay
Aye
Gottfried
Aye
Hawley
Aye
Nolan
Excused
Giglio
Aye
Weinstein
Aye
Blankenbush
Aye
Pretlow
Aye
Norris
Aye
Cook
Aye
Montesano
Aye
Glick
Aye
Ra
Aye
Aubry
Aye
Brabenec
Aye
Englebright
Aye
Dinowitz
Aye
Colton
Aye
Magnarelli
Aye
Perry
Aye
Paulin
Aye
Peoples-Stokes
Aye
Benedetto
Aye
Lavine
Aye
Lupardo
Aye
Zebrowski
Aye
Thiele
Aye
Braunstein
Aye
Dickens
Aye
Davila
Aye

A07704 Floor Votes:

A07704 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         7704--A
                                                                Cal. No. 270
 
                               2021-2022 Regular Sessions
 
                   IN ASSEMBLY
 
                                      May 20, 2021
                                       ___________
 
        Introduced  by  M.  of  A.  FERNANDEZ,  ABBATE,  DAVILA -- read once and
          referred to the Committee on Insurance -- ordered to a third  reading,
          amended  and  ordered  reprinted,  retaining its place on the order of
          third reading

        AN ACT to amend the insurance law, in relation to  providing  behavioral
          health parity (Part A); and to amend the insurance law, in relation to
          the  authorization for certain drugs for the detoxification or mainte-
          nance of a substance use disorder (Part B)
 
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section  1.  This  act enacts into law components of legislation which
     2  are necessary to effectuate provisions relating  to  mental  health  and
     3  substance use disorder parity.  Each component is wholly contained with-
     4  in  a  Part identified as Parts A through B. The effective date for each
     5  particular provision contained within such Part is set forth in the last
     6  section of such Part. Any provision in any section  contained  within  a
     7  Part,  including  the  effective date of the Part, which makes reference
     8  to a section "of this act", when used in connection with that    partic-
     9  ular  component, shall  be  deemed  to mean and refer to the correspond-
    10  ing section of the Part in which it is found. Section three of this  act
    11  sets forth the general effective date of this act.
 
    12                                   PART A
 
    13    Section  1.  Subparagraph  (D)  of  paragraph  30 of subsection (i) of
    14  section 3216 of the insurance law, as amended by section 5 of subpart  A
    15  of  part  BB  of  chapter  57 of the laws of 2019, is amended to read as
    16  follows:
    17    (D) This subparagraph shall apply to facilities in this state that are
    18  licensed, certified or otherwise authorized by the office of [alcoholism
    19  and substance abuse services] addiction services and supports  that  are

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD09970-03-2
        A. 7704--A                          2
 
     1  participating in the insurer's provider network. Coverage provided under
     2  this  paragraph  shall  not  be  subject  to  preauthorization. Coverage
     3  provided under this paragraph shall also not be  subject  to  concurrent
     4  utilization  review  during the first twenty-eight days of the inpatient
     5  admission provided that the facility notifies the insurer  of  both  the
     6  admission and the initial treatment plan within two business days of the
     7  admission  on a standardized form developed by the department in consul-
     8  tation with the  department  of  health  and  the  office  of  addiction
     9  services  and supports. The facility shall perform daily clinical review
    10  of the patient[, including periodic] and consult periodically  with  the
    11  insurer  regarding  the  patient's  progress,  course  of treatment, and
    12  discharge plan. Periodic consultation with the insurer [at or just prior
    13  to] shall occur no later than the fourteenth day of treatment [to ensure
    14  that the facility is using the evidence-based and peer reviewed clinical
    15  review tool utilized by the insurer which is designated by the office of
    16  alcoholism and substance abuse services and appropriate to  the  age  of
    17  the  patient, to ensure that the inpatient treatment is medically neces-
    18  sary for the patient]. Prior to discharge, the  facility  shall  provide
    19  the  patient  and  the insurer with a written discharge plan which shall
    20  describe arrangements for additional services needed following discharge
    21  from the inpatient facility as determined using the  evidence-based  and
    22  peer-reviewed  clinical  review  tool  utilized  by the insurer which is
    23  designated by the office of [alcoholism and  substance  abuse  services]
    24  addiction  services and supports. Prior to discharge, the facility shall
    25  indicate to the insurer whether services included in the discharge  plan
    26  are  secured  or  determined  to be reasonably available. [Any] Insurers
    27  shall actively participate in facility-initiated periodic  consultations
    28  prior  to  the patient's discharge and except where the insurer fails to
    29  do so, any utilization review of treatment provided under this  subpara-
    30  graph  may  include  a review of all services provided during such inpa-
    31  tient treatment, including all services provided during the first  twen-
    32  ty-eight  days  of  such  inpatient  treatment.  Provided,  however, the
    33  insurer shall be required to process claims for the  provision  of  such
    34  services  within the timeframes established in subsection (a) of section
    35  three thousand two hundred twenty-four-a of this article and shall  only
    36  deny  coverage for any portion of the initial twenty-eight day inpatient
    37  treatment on the basis that such treatment was not  medically  necessary
    38  if  such inpatient treatment was contrary to the evidence-based and peer
    39  reviewed clinical review tool utilized by the insurer  which  is  desig-
    40  nated  by  the  office  of  [alcoholism  and  substance  abuse services]
    41  addiction services and supports. An insured shall not have any financial
    42  obligation to the facility for any  treatment  under  this  subparagraph
    43  other  than any copayment, coinsurance, or deductible otherwise required
    44  under the policy.
    45    § 2. Subparagraph (E) of paragraph 31 of  subsection  (i)  of  section
    46  3216  of the insurance law, as amended by section 6 of subpart A of part
    47  BB of chapter 57 of the laws of 2019, is amended to read as follows:
    48    (E) This subparagraph shall apply to facilities in this state that are
    49  licensed, certified or otherwise authorized by the office of [alcoholism
    50  and substance abuse services] addiction services and  supports  for  the
    51  provision of outpatient, intensive outpatient, outpatient rehabilitation
    52  and  opioid  treatment  that are participating in the insurer's provider
    53  network. Coverage provided under this paragraph shall not be subject  to
    54  preauthorization.  Coverage  provided  under this paragraph shall not be
    55  subject to concurrent review for the  first  four  weeks  of  continuous
    56  treatment,  not  to  exceed  twenty-eight  visits, provided the facility
        A. 7704--A                          3
 
     1  notifies the insurer of both the start  of  treatment  and  the  initial
     2  treatment plan within two business days on a standardized form developed
     3  by  the department in consultation with the department of health and the
     4  office  of  addiction  services and supports. The facility shall perform
     5  clinical assessment of the patient at each visit[,  including  periodic]
     6  and  consult  periodically  with  the  insurer  regarding  the patient's
     7  progress, course of treatment, and discharge plan. Periodic consultation
     8  with the insurer [at or just prior to] shall occur  no  later  than  the
     9  fourteenth  day  of  treatment [to ensure that the facility is using the
    10  evidence-based and peer reviewed clinical review tool  utilized  by  the
    11  insurer  which  is  designated by the office of alcoholism and substance
    12  abuse services and appropriate to the age of the patient, to ensure that
    13  the outpatient treatment is medically necessary for the patient].  [Any]
    14  Insurers  shall  actively  participate  in  facility-initiated  periodic
    15  consultations prior to the patient's  discharge  and  except  where  the
    16  insurer fails to do so, any utilization review of the treatment provided
    17  under  this  subparagraph  may include a review of all services provided
    18  during such outpatient treatment, including all services provided during
    19  the first four weeks of continuous treatment, not to exceed twenty-eight
    20  visits, of such outpatient treatment.  Provided,  however,  the  insurer
    21  shall  only  deny  coverage for any portion of the initial four weeks of
    22  continuous treatment, not to exceed twenty-eight visits, for  outpatient
    23  treatment  on  the basis that such treatment was not medically necessary
    24  if such outpatient treatment was contrary to the evidence-based and peer
    25  reviewed clinical review tool utilized by the insurer  which  is  desig-
    26  nated  by  the  office  of  [alcoholism  and  substance  abuse services]
    27  addiction services and supports.  An insured shall not have  any  finan-
    28  cial  obligation  to  the facility for any treatment under this subpara-
    29  graph other than any copayment,  coinsurance,  or  deductible  otherwise
    30  required under the policy.
    31    §  3.  Subparagraph  (G)  of paragraph 35 of subsection (i) of section
    32  3216 of the insurance law, as added by section 8 of subpart A of part BB
    33  of chapter 57 of the laws of 2019, is amended to read as follows:
    34    (G) This subparagraph shall apply to hospitals in this state that  are
    35  licensed,  certified  or  otherwise  authorized  by the office of mental
    36  health that are participating in the insurer's provider  network.  Where
    37  the  policy  provides coverage for inpatient hospital care, benefits for
    38  inpatient hospital care in a hospital as defined by subdivision  ten  of
    39  section 1.03 of the mental hygiene law [provided to individuals who have
    40  not  attained  the  age of eighteen] shall not be subject to preauthori-
    41  zation. Coverage provided under this  subparagraph  shall  also  not  be
    42  subject  to concurrent utilization review during the first fourteen days
    43  of the inpatient admission, provided the facility notifies  the  insurer
    44  of both the admission and the initial treatment plan within two business
    45  days of the admission on a standardized form developed by the department
    46  in  consultation  with the department of health and the office of mental
    47  health, performs daily clinical review of the patient, and [participates
    48  in periodic consultation with the insurer to ensure that the facility is
    49  using the evidence-based and  peer  reviewed  clinical  review  criteria
    50  utilized by the insurer which is approved by the office of mental health
    51  and  appropriate to the age of the patient, to ensure that the inpatient
    52  care is medically necessary for the patient] consults periodically  with
    53  the  insurer  regarding the patient's progress, course of treatment, and
    54  discharge plan. [All] Insurers shall actively participate  in  facility-
    55  initiated  periodic  consultations  prior to the patient's discharge and
    56  except where the insurer fails to do so, all  treatment  provided  under
        A. 7704--A                          4
 
     1  this  subparagraph may be reviewed retrospectively. Where care is denied
     2  retrospectively, an insured shall not have any financial  obligation  to
     3  the  facility  for  any treatment under this subparagraph other than any
     4  copayment, coinsurance, or deductible otherwise required under the poli-
     5  cy.
     6    § 4. Subparagraph (G) of paragraph 5 of subsection (l) of section 3221
     7  of  the insurance law, as added by section 14 of subpart A of part BB of
     8  chapter 57 of the laws of 2019, is amended to read as follows:
     9    (G) This subparagraph shall apply to hospitals in this state that  are
    10  licensed,  certified  or  otherwise  authorized  by the office of mental
    11  health that are participating in the insurer's provider  network.  Where
    12  the  policy  provides coverage for inpatient hospital care, benefits for
    13  inpatient hospital care in a hospital as defined by subdivision  ten  of
    14  section 1.03 of the mental hygiene law [provided to individuals who have
    15  not  attained  the  age of eighteen] shall not be subject to preauthori-
    16  zation. Coverage provided under this  subparagraph  shall  also  not  be
    17  subject  to concurrent utilization review during the first fourteen days
    18  of the inpatient admission, provided the facility notifies  the  insurer
    19  of both the admission and the initial treatment plan within two business
    20  days of the admission on a standardized form developed by the department
    21  in  consultation  with the department of health and the office of mental
    22  health, performs daily clinical review of the patient, and [participates
    23  in periodic consultation with the insurer to ensure that the facility is
    24  using the evidence-based and  peer  reviewed  clinical  review  criteria
    25  utilized by the insurer which is approved by the office of mental health
    26  and  appropriate to the age of the patient, to ensure that the inpatient
    27  care is medically necessary for the patient] consults periodically  with
    28  the  insurer  regarding the patient's progress, course of treatment, and
    29  discharge plan. [All] Insurers shall actively participate  in  facility-
    30  initiated  periodic  consultations  prior to the patient's discharge and
    31  except where the insurer fails to do so, all  treatment  provided  under
    32  this  subparagraph may be reviewed retrospectively. Where care is denied
    33  retrospectively, an insured shall not have any financial  obligation  to
    34  the  facility  for  any treatment under this subparagraph other than any
    35  copayment, coinsurance, or deductible otherwise required under the poli-
    36  cy.
    37    § 5. Subparagraph (D) of paragraph 6 of subsection (l) of section 3221
    38  of the insurance law, as amended by section 15 of subpart A of  part  BB
    39  of chapter 57 of the laws of 2019, is amended to read as follows:
    40    (D) This subparagraph shall apply to facilities in this state that are
    41  licensed, certified or otherwise authorized by the office of [alcoholism
    42  and  substance  abuse services] addiction services and supports that are
    43  participating in the insurer's provider network. Coverage provided under
    44  this paragraph  shall  not  be  subject  to  preauthorization.  Coverage
    45  provided  under  this  paragraph shall also not be subject to concurrent
    46  utilization review during the first twenty-eight days of  the  inpatient
    47  admission  provided  that  the facility notifies the insurer of both the
    48  admission and the initial treatment plan within two business days of the
    49  admission on a standardized form developed by the department in  consul-
    50  tation  with  the  department  of  health  and  the  office of addiction
    51  services and supports. The facility shall perform daily clinical  review
    52  of  the  patient[, including periodic] and consult periodically with the
    53  insurer regarding the  patient's  progress,  course  of  treatment,  and
    54  discharge plan. Periodic consultation with the insurer [at or just prior
    55  to] shall occur no later than the fourteenth day of treatment [to ensure
    56  that the facility is using the evidence-based and peer reviewed clinical
        A. 7704--A                          5

     1  review tool utilized by the insurer which is designated by the office of
     2  alcoholism  and  substance  abuse services and appropriate to the age of
     3  the patient, to ensure that the inpatient treatment is medically  neces-
     4  sary  for  the  patient]. Prior to discharge, the facility shall provide
     5  the patient and the insurer with a written discharge  plan  which  shall
     6  describe arrangements for additional services needed following discharge
     7  from  the  inpatient facility as determined using the evidence-based and
     8  peer-reviewed clinical review tool utilized  by  the  insurer  which  is
     9  designated  by  the  office of [alcoholism and substance abuse services]
    10  addiction services and supports. Prior to discharge, the facility  shall
    11  indicate  to the insurer whether services included in the discharge plan
    12  are secured or determined to be  reasonably  available.  [Any]  Insurers
    13  shall  actively participate in facility-initiated periodic consultations
    14  prior to the patient's discharge and except where the insurer  fails  to
    15  do  so, any utilization review of treatment provided under this subpara-
    16  graph may include a review of all services provided  during  such  inpa-
    17  tient  treatment, including all services provided during the first twen-
    18  ty-eight days  of  such  inpatient  treatment.  Provided,  however,  the
    19  insurer  shall  be  required to process claims for the provision of such
    20  services within the timeframes established in subsection (a) of  section
    21  three  thousand two hundred twenty-four-a of this article and shall only
    22  deny coverage for any portion of the initial twenty-eight day  inpatient
    23  treatment  on  the basis that such treatment was not medically necessary
    24  if such inpatient treatment was contrary to the evidence-based and  peer
    25  reviewed  clinical  review  tool utilized by the insurer which is desig-
    26  nated by  the  office  of  [alcoholism  and  substance  abuse  services]
    27  addiction services and supports. An insured shall not have any financial
    28  obligation  to  the  facility  for any treatment under this subparagraph
    29  other than any copayment, coinsurance, or deductible otherwise  required
    30  under the policy.
    31    § 6. Subparagraph (E) of paragraph 7 of subsection (l) of section 3221
    32  of  the  insurance law, as amended by section 17 of subpart A of part BB
    33  of chapter 57 of the laws of 2019, is amended to read as follows:
    34    (E) This subparagraph shall apply to facilities in this state that are
    35  licensed, certified or otherwise authorized by the office of [alcoholism
    36  and substance abuse services] addiction services and  supports  for  the
    37  provision of outpatient, intensive outpatient, outpatient rehabilitation
    38  and  opioid  treatment  that are participating in the insurer's provider
    39  network. Coverage provided under this paragraph shall not be subject  to
    40  preauthorization.  Coverage  provided  under this paragraph shall not be
    41  subject to concurrent review for the  first  four  weeks  of  continuous
    42  treatment,  not  to  exceed  twenty-eight  visits, provided the facility
    43  notifies the insurer of both the start  of  treatment  and  the  initial
    44  treatment plan within two business days on a standardized form developed
    45  by  the department in consultation with the department of health and the
    46  office of addiction services and supports. The  facility  shall  perform
    47  clinical  assessment  of the patient at each visit[, including periodic]
    48  and consult  periodically  with  the  insurer  regarding  the  patient's
    49  progress, course of treatment, and discharge plan. Periodic consultation
    50  with  the  insurer  [at  or just prior to] shall occur no later than the
    51  fourteenth day of treatment [to ensure that the facility  is  using  the
    52  evidence-based  and  peer  reviewed clinical review tool utilized by the
    53  insurer which is designated by the office of  alcoholism  and  substance
    54  abuse services and appropriate to the age of the patient, to ensure that
    55  the  outpatient treatment is medically necessary for the patient]. [Any]
    56  Insurers  shall  actively  participate  in  facility-initiated  periodic
        A. 7704--A                          6
 
     1  consultations  prior  to  the  patient's  discharge and except where the
     2  insurer fails to do so, any utilization review of the treatment provided
     3  under this subparagraph may include a review of  all  services  provided
     4  during such outpatient treatment, including all services provided during
     5  the first four weeks of continuous treatment, not to exceed twenty-eight
     6  visits,  of  such  outpatient  treatment. Provided, however, the insurer
     7  shall only deny coverage for any portion of the initial  four  weeks  of
     8  continuous  treatment, not to exceed twenty-eight visits, for outpatient
     9  treatment on the basis that such treatment was not  medically  necessary
    10  if such outpatient treatment was contrary to the evidence-based and peer
    11  reviewed  clinical  review  tool utilized by the insurer which is desig-
    12  nated by  the  office  of  [alcoholism  and  substance  abuse  services]
    13  addiction  services  and supports.  An insured shall not have any finan-
    14  cial obligation to the facility for any treatment  under  this  subpara-
    15  graph  other  than  any  copayment, coinsurance, or deductible otherwise
    16  required under the policy.
    17    § 7. Subsection (a) of section 3224-a of the insurance law, as amended
    18  by chapter 237 of the laws of 2009, is amended to read as follows:
    19    (a) Except in a case where the obligation of an insurer or  an  organ-
    20  ization  or corporation licensed or certified pursuant to article forty-
    21  three or forty-seven of this chapter or article forty-four of the public
    22  health law to pay a claim submitted by a policyholder or person  covered
    23  under  such policy ("covered person") or make a payment to a health care
    24  provider is not reasonably clear, or when there is  a  reasonable  basis
    25  supported  by  specific  information  available for review by the super-
    26  intendent that such claim or bill for health care services rendered  was
    27  submitted  fraudulently,  such  insurer  or  organization or corporation
    28  shall pay the claim to a  policyholder  or  covered  person  or  make  a
    29  payment  to  a  health  care provider within thirty days of receipt of a
    30  claim or bill for services rendered that is transmitted via the internet
    31  or electronic mail, or forty-five days of receipt of a claim or bill for
    32  services rendered that is submitted by other means,  such  as  paper  or
    33  facsimile.  The obligation of an insurer or organization to make payment
    34  to a health care provider for mental health or  substance  use  disorder
    35  services  that  are not subject to preauthorization or concurrent review
    36  pursuant to sections three thousand two hundred sixteen, three  thousand
    37  two  hundred  twenty-one,  or  four thousand three hundred three of this
    38  chapter shall not be considered not reasonably clear solely because  the
    39  insurer  or  organization  intends to perform concurrent review for such
    40  services before or after the expiration of the timeframes established by
    41  this subsection.
    42    § 8. Paragraph 8 of subsection (g) of section 4303  of  the  insurance
    43  law, as added by section 23 of subpart A of part BB of chapter 57 of the
    44  laws of 2019, is amended to read as follows:
    45    (8)  This  paragraph  shall  apply to hospitals in this state that are
    46  licensed, certified or otherwise authorized  by  the  office  of  mental
    47  health  that are participating in the [corporation's] insurer's provider
    48  network. Where the contract provides  coverage  for  inpatient  hospital
    49  care,  benefits  for inpatient hospital care in a hospital as defined by
    50  subdivision ten of section 1.03 of the mental hygiene law  [provided  to
    51  individuals  who  have  not  attained  the age of eighteen] shall not be
    52  subject to preauthorization.  Coverage  provided  under  this  paragraph
    53  shall  also  not  be subject to concurrent utilization review during the
    54  first fourteen days of the inpatient admission,  provided  the  facility
    55  notifies the [corporation] insurer of both the admission and the initial
    56  treatment  plan within two business days of the admission on a standard-
        A. 7704--A                          7
 
     1  ized form developed by the department in consultation with  the  depart-
     2  ment  of health and the office of mental health, performs daily clinical
     3  review of the patient, and [participates in periodic  consultation  with
     4  the  corporation to ensure that the facility is using the evidence-based
     5  and peer reviewed clinical review criteria utilized by  the  corporation
     6  which  is approved by the office of mental health and appropriate to the
     7  age of the patient, to ensure  that  the  inpatient  care  is  medically
     8  necessary  for  the  patient]  consults  periodically  with  the insurer
     9  regarding the patient's progress, course  of  treatment,  and  discharge
    10  plan.    [All] Insurers shall actively participate in facility-initiated
    11  periodic consultations prior to the patient's discharge and except where
    12  the insurer fails to do so, all treatment provided under this  paragraph
    13  may  be  reviewed retrospectively. Where care is denied retrospectively,
    14  an insured shall not have any financial obligation to the  facility  for
    15  any  treatment  under  this  paragraph other than any copayment, coinsu-
    16  rance, or deductible otherwise required under the contract.
    17    § 9. Paragraph 4 of subsection (k) of section 4303  of  the  insurance
    18  law,  as  amended by section 26 of subpart A of part BB of chapter 57 of
    19  the laws of 2019, is amended to read as follows:
    20    (4) This paragraph shall apply to facilities in this  state  that  are
    21  licensed, certified or otherwise authorized by the office of [alcoholism
    22  and  substance  abuse services] addiction services and supports that are
    23  participating in the [corporation's] insurer's provider network.  Cover-
    24  age  provided  under this subsection shall not be subject to preauthori-
    25  zation. Coverage provided  under  this  subsection  shall  also  not  be
    26  subject  to  concurrent utilization review during the first twenty-eight
    27  days of the inpatient admission provided that the facility notifies  the
    28  [corporation]  insurer  of  both the admission and the initial treatment
    29  plan within two business days of the admission on  a  standardized  form
    30  developed  by  the  department  in  consultation  with the department of
    31  health and the office of addiction services and supports.  The  facility
    32  shall  perform daily clinical review of the patient[, including periodic
    33  consultation] and consult periodically with the  insurer  regarding  the
    34  patient's  progress,  course of treatment, and discharge plan.  Periodic
    35  consultation with the [corporation at or just prior  to]  insurer  shall
    36  occur not later than the fourteenth day of treatment [to ensure that the
    37  facility  is  using the evidence-based and peer reviewed clinical review
    38  tool utilized by the corporation which is designated by  the  office  of
    39  alcoholism  and  substance  abuse services and appropriate to the age of
    40  the patient, to ensure that the inpatient treatment is medically  neces-
    41  sary  for  the  patient]. Prior to discharge, the facility shall provide
    42  the patient and the [corporation] insurer with a written discharge  plan
    43  which shall describe arrangements for additional services needed follow-
    44  ing  discharge  from  the  inpatient  facility  as  determined using the
    45  evidence-based and peer-reviewed clinical review tool  utilized  by  the
    46  [corporation]  insurer  which is designated by the office of [alcoholism
    47  and substance abuse services] addiction services and supports. Prior  to
    48  discharge,  the  facility  shall  indicate  to the [corporation] insurer
    49  whether services included in the discharge plan are  secured  or  deter-
    50  mined to be reasonably available.  [Any] Insurers shall actively partic-
    51  ipate   in   facility-initiated  periodic  consultations  prior  to  the
    52  patient's discharge and except where the insurer fails  to  do  so,  any
    53  utilization  review  of  treatment  provided  under  this  paragraph may
    54  include a review of all services provided during such  inpatient  treat-
    55  ment, including all services provided during the first twenty-eight days
    56  of such inpatient treatment. Provided, however, the [corporation] insur-
        A. 7704--A                          8
 
     1  er  shall  be  required  to  process  claims  for  the provision of such
     2  services within the timeframes established in subsection (a) of  section
     3  three  thousand two hundred twenty-four-a of this chapter and shall only
     4  deny  coverage for any portion of the initial twenty-eight day inpatient
     5  treatment on the basis that such treatment was not  medically  necessary
     6  if  such inpatient treatment was contrary to the evidence-based and peer
     7  reviewed clinical review tool  utilized  by  the  [corporation]  insurer
     8  which  is  designated  by  the office of [alcoholism and substance abuse
     9  services] addiction services and supports.   An insured shall  not  have
    10  any  financial  obligation  to the facility for any treatment under this
    11  paragraph other than any copayment, coinsurance, or deductible otherwise
    12  required under the contract.
    13    § 10. Paragraph 5 of subsection (l) of section 4303 of  the  insurance
    14  law,  as  amended by section 28 of subpart A of part BB of chapter 57 of
    15  the laws of 2019, is amended to read as follows:
    16    (5) This paragraph shall apply to facilities in this  state  that  are
    17  licensed, certified or otherwise authorized by the office of [alcoholism
    18  and  substance  abuse  services] addiction services and supports for the
    19  provision of outpatient, intensive outpatient, outpatient rehabilitation
    20  and opioid treatment that are participating in the corporation's provid-
    21  er network. Coverage provided under this subsection shall not be subject
    22  to preauthorization. Coverage provided under this subsection  shall  not
    23  be  subject  to concurrent review for the first four weeks of continuous
    24  treatment, not to exceed  twenty-eight  visits,  provided  the  facility
    25  notifies  the corporation of both the start of treatment and the initial
    26  treatment plan within two business days on a standardized form developed
    27  by the department in consultation with the department of health and  the
    28  office  of  addiction  services and supports. The facility shall perform
    29  clinical assessment of the patient at each visit[,  including  periodic]
    30  and  consult  periodically  with  the  insurer  regarding  the patient's
    31  progress, course of treatment, and discharge plan. Periodic consultation
    32  with the corporation [at or just prior to] shall occur no later than the
    33  fourteenth day of treatment [to ensure that the facility  is  using  the
    34  evidence-based  and  peer  reviewed clinical review tool utilized by the
    35  corporation  which  is  designated  by  the  office  of  alcoholism  and
    36  substance  abuse  services and appropriate to the age of the patient, to
    37  ensure that the outpatient treatment  is  medically  necessary  for  the
    38  patient]. [Any] Insurers shall actively participate in facility-initiat-
    39  ed  periodic  consultations  prior to the patient's discharge and except
    40  where the insurer fails to do so, any utilization review of  the  treat-
    41  ment  provided under this paragraph may include a review of all services
    42  provided  during  such  outpatient  treatment,  including  all  services
    43  provided  during  the  first  four weeks of continuous treatment, not to
    44  exceed twenty-eight visits, of such  outpatient  treatment.    Provided,
    45  however, the corporation shall only deny coverage for any portion of the
    46  initial  four  weeks of continuous treatment, not to exceed twenty-eight
    47  visits, for outpatient treatment on the basis that  such  treatment  was
    48  not medically necessary if such outpatient treatment was contrary to the
    49  evidence-based  and  peer  reviewed clinical review tool utilized by the
    50  corporation which  is  designated  by  the  office  of  [alcoholism  and
    51  substance  abuse services] addiction services and supports. [A subscrib-
    52  er] An insured shall not have any financial obligation to  the  facility
    53  for any treatment under this paragraph other than any copayment, coinsu-
    54  rance, or deductible otherwise required under the contract.
    55    §  11.  Section  109  of  the insurance law is amended by adding a new
    56  subsection (e) to read as follows:
        A. 7704--A                          9
 
     1    (e) In addition to any right of action granted to  the  superintendent
     2  pursuant to this section, any person who has been injured by reason of a
     3  violation of paragraphs thirty, thirty-one, thirty-one-a and thirty-five
     4  of  subsection  (i) of section three thousand two hundred sixteen, para-
     5  graphs  five,  six, seven and seven-a of subsection (l) of section three
     6  thousand two hundred twenty-one, and subsections (g), (k), (l) or  (l-1)
     7  of  section  four  thousand  three  hundred  three of this chapter by an
     8  insurer subject to article thirty-two or forty-three of this chapter may
     9  bring an action in his or her own name to enjoin such  unlawful  act  or
    10  practice, an action to recover his or her actual damages or one thousand
    11  dollars,  whichever  is greater, or both such actions. The court may, in
    12  its discretion, award the prevailing plaintiff in such action  an  addi-
    13  tional award not to exceed five thousand dollars, if the court finds the
    14  defendant  willfully  violated the provisions of this section. The court
    15  may award reasonable attorneys' fees to a prevailing plaintiff.
    16    § 12. This act shall take effect January 1, 2023.
 
    17                                   PART B

    18    Section 1. Subparagraph (A) of paragraph 31-a  of  subsection  (i)  of
    19  section  3216  of the insurance law, as added by chapter 748 of the laws
    20  of 2019, is amended to read as follows:
    21    (A) No policy that provides medical, major medical or similar  compre-
    22  hensive-type  coverage  and provides coverage for prescription drugs for
    23  medication for the treatment of a substance use disorder  shall  require
    24  prior  authorization  for  an  initial  or renewal prescription for such
    25  drugs for the detoxification or maintenance of a substance use disorder,
    26  including  all  buprenorphine  products,  methadone  [or],  long  acting
    27  injectable  naltrexone [for detoxification or maintenance treatment of a
    28  substance use disorder] and  medication  for  opioid  overdose  reversal
    29  prescribed  or  dispensed  to  an  individual  covered under the policy,
    30  except where otherwise prohibited by law.
    31    § 2. Subparagraph (A) of paragraph 7-a of subsection  (l)  of  section
    32  3221  of the insurance law, as added by chapter 748 of the laws of 2019,
    33  is amended to read as follows:
    34    (A) No policy that provides medical, major medical or similar  compre-
    35  hensive-type small group coverage and provides coverage for prescription
    36  drugs for medication for the treatment of a substance use disorder shall
    37  require  prior  authorization for an initial or renewal prescription for
    38  such drugs for the detoxification or  maintenance  of  a  substance  use
    39  disorder,  including  all buprenorphine products, methadone, long acting
    40  injectable naltrexone,  and  medication  for  opioid  overdose  reversal
    41  prescribed  or  dispensed  to  an  individual  covered under the policy,
    42  except where otherwise prohibited by law.  Every  policy  that  provides
    43  medical,  major medical or similar comprehensive-type large group cover-
    44  age shall provide coverage for prescription drugs for medication for the
    45  treatment of a substance use disorder and shall provide immediate cover-
    46  age for all buprenorphine products, methadone [or], long acting injecta-
    47  ble naltrexone, and medication for opioid overdose  reversal  prescribed
    48  or  dispensed  to  an  individual covered under the policy without prior
    49  authorization for the  detoxification  or  maintenance  treatment  of  a
    50  substance use disorder, except where otherwise prohibited by law.
    51    § 3. Subparagraph (A) of paragraph (l-1) of section 4303 of the insur-
    52  ance  law,  as  added  by chapter 748 of the laws of 2019, is amended to
    53  read as follows:
        A. 7704--A                         10
 
     1    (A) No contract  that  provides  medical,  major  medical  or  similar
     2  comprehensive-type  individual  or  small  group  coverage  and provides
     3  coverage for prescription drugs for medication for the  treatment  of  a
     4  substance  use disorder shall require prior authorization for an initial
     5  or renewal prescription for such drugs for the detoxification or mainte-
     6  nance of a substance use disorder, including all buprenorphine products,
     7  methadone,  long acting injectable naltrexone, and medication for opioid
     8  overdose reversal prescribed or dispensed to an individual covered under
     9  the contract, except where otherwise prohibited by law.  Every  contract
    10  that  provides  medical,  major  medical,  or similar comprehensive-type
    11  large group coverage shall provide coverage for prescription  drugs  for
    12  medication  for  the  treatment  of  a  substance use disorder and shall
    13  provide immediate coverage for  all  buprenorphine  products,  methadone
    14  [or], long acting injectable naltrexone, and medication for opioid over-
    15  dose reversal prescribed or dispensed to an individual covered under the
    16  contract  without  prior authorization for the detoxification or mainte-
    17  nance treatment of a substance  use  disorder,  except  where  otherwise
    18  prohibited by law.
    19    § 4. This act shall take effect immediately.
    20    § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
    21  sion,  section  or  part  of  this act shall be adjudged by any court of
    22  competent  jurisdiction to be invalid, such judgment  shall  not affect,
    23  impair,  or  invalidate  the remainder thereof, but shall be confined in
    24  its operation to the clause, sentence, paragraph, subdivision,   section
    25  or part thereof directly involved in the controversy in which such judg-
    26  ment shall have been rendered. It is hereby declared to be the intent of
    27  the  legislature  that  this  act  would  have been enacted even if such
    28  invalid provisions had not been included herein.
    29    § 3. This act shall take effect immediately  provided,  however,  that
    30  the  applicable effective date of Parts A through B of this act shall be
    31  as specifically set forth in the last section of such Parts.