Amd SS3216, 3221, 4303, 4902, 4903 & 4904, Ins L; amd SS4902, 4903 & 4904, Pub Health L
Relates to insurance coverage for diagnosis and treatment of substance use disorder benefits; creates a workgroup to study and make recommendations on improving access to and the availability of chemical dependency or substance use disorder treatment services.
STATE OF NEW YORK
________________________________________________________________________
9943--B
IN ASSEMBLY
June 2, 2014
___________
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Cusick,
Weisenberg, Ortiz, Gunther, Skoufis, Rosenthal, Titone, Mosley,
Peoples-Stokes, Galef, Barrett, Gottfried, Fahy, Braunstein, Camara,
Cook, Hooper, Magee, O'Donnell, Rivera, Saladino, Sweeney, Thiele) --
read once and referred to the Committee on Insurance -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee -- again reported from said committee with amend-
ments, ordered reprinted as amended and recommitted to said committee
AN ACT to amend the insurance law and the public health law, in relation
to requiring health insurance coverage for diagnosis and treatment of
substance use disorder treatment services and creating a workgroup to
study and make recommendations
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subsection (i) of section 3216 of the insurance law is
2 amended by adding a new paragraph 30 to read as follows:
3 (30) (A) Every policy that provides medical, major-medical or similar
4 comprehensive-type coverage shall include coverage for diagnosis and
5 treatment of substance use disorder benefits pursuant to the federal
6 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
7 Equity Act of 2008, as amended, or other applicable federal and state
8 statutes and rules and regulations promulgated thereto which require
9 parity between mental health or substance use disorder benefits and
10 medical/surgical benefits with respect to financial requirements and
11 treatment or which require coverage of such treatment, whichever
12 provides a benefit that is more advantageous to the policyholder as
13 determined by the superintendent. Such coverage shall include both inpa-
14 tient and outpatient treatment, including detoxification and rehabili-
15 tation services.
16 (B) In the event of an adverse determination for substance use disor-
17 der treatment services, the health plan shall continue to provide cover-
18 age and reimburse for all such services until the insured has exhausted
19 all appeals, both internal and external, or otherwise notifies the
20 health plan in writing that he or she has decided to not move forward
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD15361-09-4
A. 9943--B 2
1 with the appeals process. The health plan shall ensure that an insured
2 shall not incur any greater out-of-pocket costs for substance use disor-
3 der treatment services rendered while the provider is appealing an
4 adverse determination for such services than the insured would have
5 incurred if such services were approved by the utilization review agent.
6 § 2. Subsection (l) of section 3221 of the insurance law is amended by
7 adding a new paragraph 19 to read as follows:
8 (19) (A) Every group or blanket policy delivered or issued for deliv-
9 ery in this state which provides major medical or similar comprehen-
10 sive-type coverage shall include specific coverage for diagnosis and
11 treatment of substance use disorder benefits pursuant to the federal
12 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
13 Equity Act of 2008, as amended, or other applicable federal and state
14 statutes and rules and regulations promulgated thereto which require
15 parity between mental health or substance use disorder benefits and
16 medical/surgical benefits with respect to financial requirements and
17 treatment or which require coverage of such treatment, whichever
18 provides a benefit that is more advantageous to the policyholder as
19 determined by the superintendent. Such coverage shall include both inpa-
20 tient and outpatient treatment, including detoxification and rehabili-
21 tation services.
22 (B) In the event of an adverse determination for chemical dependence
23 or substance use disorder treatment services, the health plan shall
24 continue to provide coverage and reimburse for all such services until
25 the insured has exhausted all appeals, both internal and external, or
26 otherwise notifies the health plan in writing that he or she has decided
27 to not move forward with the appeals process. The health plan shall
28 ensure that an insured shall not incur any greater out-of-pocket costs
29 for substance use disorder treatment services rendered while the provid-
30 er is appealing an adverse determination for such services than the
31 insured would have incurred if such services were approved by the utili-
32 zation review agent.
33 § 3. Section 4303 of the insurance law is amended by adding a new
34 subsection (oo) to read as follows:
35 (oo) (1) A medical expense indemnity corporation, a hospital service
36 corporation or a health service corporation which provides major medical
37 or similar comprehensive-type coverage shall include specific coverage
38 for diagnosis and treatment of substance use disorder benefits pursuant
39 to the federal Paul Wellstone and Pete Domenici Mental Health Parity and
40 Addiction Equity Act of 2008, as amended, or other applicable federal
41 and state statutes and rules and regulations promulgated thereto which
42 require parity between mental health or substance use disorder benefits
43 and medical/surgical benefits with respect to financial requirements and
44 treatment or which require coverage of such treatment, whichever
45 provides a benefit that is more advantageous to the policyholder as
46 determined by the superintendent. Such coverage shall include both inpa-
47 tient and outpatient treatment, including detoxification and rehabili-
48 tation services.
49 (2) In the event of an adverse determination for chemical dependence
50 or substance use disorder treatment services, the health plan shall
51 continue to provide coverage and reimburse for all such services until
52 the insured has exhausted all appeals, both internal and external, or
53 otherwise notifies the health plan in writing that he or she has decided
54 to not move forward with the appeals process. The health plan shall
55 ensure that an insured shall not incur any greater out-of pocket costs
56 for substance use disorder treatment services rendered while the provid-
A. 9943--B 3
1 er is appealing an adverse determination for such services than the
2 insured would have incurred if such services were approved by the utili-
3 zation review agent.
4 § 4. Section 4902 of the insurance law is amended by adding two new
5 subsections (c) and (d) to read as follows:
6 (c) i. When conducting a utilization review for purposes of determin-
7 ing health care coverage for chemical dependence or substance use disor-
8 ders, a utilization review agent shall be a health care provider who
9 specializes in behavioral health and who has experience in the delivery
10 of chemical dependence or substance use disorder courses of treatment to
11 supervise and oversee the medical management decisions relating to such
12 treatment.
13 ii. A utilization review agent shall utilize recognized evidence-based
14 and peer reviewed clinical review criteria that is appropriate to the
15 age of the patient and is deemed appropriate and approved for such use
16 by the commissioner of the office of alcoholism and substance abuse
17 services in consultation with the commissioner of health and the super-
18 intendent.
19 iii. The office of alcoholism and substance abuse services in consul-
20 tation with the commissioner of health and the superintendent shall
21 approve a recognized evidence-based and peer reviewed clinical review
22 criteria, in addition to any other approved evidence-based and peer
23 reviewed clinical review criteria.
24 (d) Where an insured's healthcare provider believes an immediate
25 appeal of an adverse determination for treatment relating to chemical
26 dependence or substance use disorder is warranted, all internal appeals
27 shall be conducted on an expedited basis as set forth in subsection (b)
28 of section four thousand nine hundred four of this article. Where an
29 insured's health care provider determines that a delay in providing
30 chemical dependence or substance use disorder treatment would pose a
31 serious threat to the health or safety of the insured, external appeals
32 of utilization review determination will be conducted on an expedited
33 basis as set forth in paragraph three of subsection (b) of section four
34 thousand nine hundred fourteen of this article.
35 § 5. Subsection (c) of section 4903 of the insurance law, as amended
36 by chapter 237 of the laws of 2009, is amended to read as follows:
37 (c) A utilization review agent shall make a determination involving
38 continued or extended health care services, additional services for an
39 insured undergoing a course of continued treatment prescribed by a
40 health care provider, requests for treatment for chemical dependence or
41 substance use disorder, or home health care services following an inpa-
42 tient hospital admission, and shall provide notice of such determination
43 to the insured or the insured's designee, which may be satisfied by
44 notice to the insured's health care provider, by telephone and in writ-
45 ing within one business day of receipt of the necessary information
46 except, with respect to home health care services following an inpatient
47 hospital admission or requests for treatment for chemical dependence or
48 substance use disorder, within seventy-two hours of receipt of the
49 necessary information when the day subsequent to the request falls on a
50 weekend or holiday. Notification of continued or extended services shall
51 include the number of extended services approved, the new total of
52 approved services, the date of onset of services and the next review
53 date. Provided that a request for home health care services and all
54 necessary information is submitted to the utilization review agent prior
55 to discharge from an inpatient hospital admission pursuant to this
56 subsection, a utilization review agent shall not deny, on the basis of
A. 9943--B 4
1 medical necessity or lack of prior authorization, coverage for home
2 health care services while a determination by the utilization review
3 agent is pending. Provided that a request for treatment for chemical
4 dependence or substance use disorder and all necessary information is
5 submitted to the utilization review agent pursuant to this subsection, a
6 utilization review agent shall not deny, on the basis of medical neces-
7 sity or lack of prior authorization, coverage for chemical dependence or
8 substance use disorder treatment while a determination by the utiliza-
9 tion review agent is pending. Provided that upon admission to inpatient
10 and residential treatment for chemical dependency or substance use
11 disorder, the utilization review agent shall not deny, on the basis of
12 medical necessity or lack of prior authorization, when notice of admis-
13 sion for purposes of care coordination was provided to the utilization
14 review agent within twenty-four hours of an admission; and a request for
15 treatment for chemical dependence or substance use disorder and all
16 necessary information is submitted to the utilization review agent
17 pursuant to this subsection.
18 § 6. Subsection (b) of section 4904 of the insurance law, as amended
19 by chapter 237 of the laws of 2009, is amended to read as follows:
20 (b) A utilization review agent shall establish an expedited appeal
21 process for appeal of an adverse determination involving (1) continued
22 or extended health care services, procedures or treatments or additional
23 services for an insured undergoing a course of continued treatment
24 prescribed by a health care provider or home health care services
25 following discharge from an inpatient hospital admission pursuant to
26 subsection (c) of section four thousand nine hundred three of this arti-
27 cle or (2) an adverse determination in which the health care provider
28 believes an immediate appeal is warranted except any retrospective
29 determination. Such process shall include mechanisms which facilitate
30 resolution of the appeal including but not limited to the sharing of
31 information from the insured's health care provider and the utilization
32 review agent by telephonic means or by facsimile. The utilization review
33 agent shall provide reasonable access to its clinical peer reviewer
34 within one business day of receiving notice of the taking of an expe-
35 dited appeal. Expedited appeals shall be determined within two business
36 days of receipt of necessary information to conduct such appeal. Expe-
37 dited appeals which do not result in a resolution satisfactory to the
38 appealing party may be further appealed through the standard appeal
39 process, or through the external appeal process pursuant to section four
40 thousand nine hundred fourteen of this article as applicable. Provided
41 that the insured or the insured's health care provider notifies the
42 utilization review agent of its intent to file an external appeal imme-
43 diately upon receipt of an appeal determination and a request for an
44 expedited external appeal for treatment of chemical dependence or
45 substance use disorder and all necessary information is submitted within
46 twenty-four hours of receipt of an appeal determination, a utilization
47 review agent shall not deny, on the basis of medical necessity or lack
48 of prior authorization, coverage for such treatment while a determi-
49 nation by the external review agent is pending.
50 § 7. Section 4902 of the public health law is amended by adding two
51 new subdivisions 3 and 4 to read as follows:
52 3. i. When conducting a utilization review for purposes of determining
53 health care coverage for chemical dependence or substance use disorders,
54 a utilization review agent shall be a health care provider who special-
55 izes in behavioral health and who has experience in the delivery of
56 chemical dependence or substance use disorder courses of treatment to
A. 9943--B 5
1 supervise and oversee the medical management decisions relating to such
2 treatment.
3 ii. A utilization review agent shall utilize recognized evidence-based
4 and peer reviewed clinical review criteria that is appropriate to the
5 age of the patient and is deemed appropriate and approved for such use
6 by the commissioner of the office of alcoholism and substance abuse
7 services in consultation with the commissioner and the superintendent of
8 financial services.
9 iii. The office of alcoholism and substance abuse services in consul-
10 tation with the commissioner and the superintendent of financial
11 services shall approve a recognized evidence-based and peer reviewed
12 clinical review criteria, in addition to any other approved evidence-
13 based and peer reviewed clinical review criteria.
14 4. Where an insured's healthcare provider believes an immediate appeal
15 of an adverse determination for treatment relating to chemical depend-
16 ence or substance use disorder is warranted, all internal appeals shall
17 be conducted on an expedited basis as set forth in subsection (b) of
18 section four thousand nine hundred four of this title. Where an
19 enrollee's health care provider determines that a delay in providing
20 chemical dependence or substance use disorder treatment would pose a
21 serious threat to the health or safety of the enrollee, external appeals
22 of utilization review determinations will be conducted on an expedited
23 basis as set forth in paragraph (c) of subdivision two of section four
24 thousand nine hundred fourteen of this article.
25 § 8. Subdivision 3 of section 4903 of the public health law, as
26 amended by chapter 237 of the laws of 2009, is amended to read as
27 follows:
28 3. A utilization review agent shall make a determination involving
29 continued or extended health care services, additional services for an
30 enrollee undergoing a course of continued treatment prescribed by a
31 health care provider, requests for treatment for chemical dependence or
32 substance use disorder, or home health care services following an inpa-
33 tient hospital admission, and shall provide notice of such determination
34 to the enrollee or the enrollee's designee, which may be satisfied by
35 notice to the enrollee's health care provider, by telephone and in writ-
36 ing within one business day of receipt of the necessary information
37 except, with respect to home health care services following an inpatient
38 hospital admission, or requests for treatment for chemical dependence or
39 substance use disorder, within seventy-two hours of receipt of the
40 necessary information when the day subsequent to the request falls on a
41 weekend or holiday. Notification of continued or extended services shall
42 include the number of extended services approved, the new total of
43 approved services, the date of onset of services and the next review
44 date. Provided that a request for home health care services and all
45 necessary information is submitted to the utilization review agent prior
46 to discharge from an inpatient hospital admission pursuant to this
47 subdivision, a utilization review agent shall not deny, on the basis of
48 medical necessity or lack of prior authorization, coverage for home
49 health care services while a determination by the utilization review
50 agent is pending. Provided that a request for treatment for chemical
51 dependence or substance use disorder and all necessary information is
52 submitted to the utilization review agent pursuant to this subdivision,
53 a utilization review agent shall not deny, on the basis of medical
54 necessity or lack of prior authorization, coverage for chemical depend-
55 ence or substance use disorder treatment services while a determination
56 by the utilization review agent is pending. Provided that, upon admis-
A. 9943--B 6
1 sion to inpatient and residential treatment, the utilization review
2 agent shall not deny, on the basis of medical necessity or lack of prior
3 authorization, when notice of admission for purposes of care coordi-
4 nation was provided to the utilization review agent within twenty-four
5 hours of an admission; and a request for treatment for substance use
6 disorder and all necessary information is submitted to the utilization
7 review agent pursuant to this subdivision.
8 § 9. Subdivision 2 of section 4904 of the public health law, as
9 amended by chapter 237 of the laws of 2009, is amended to read as
10 follows:
11 2. A utilization review agent shall establish an expedited appeal
12 process for appeal of an adverse determination involving:
13 (a) continued or extended health care services, procedures or treat-
14 ments or additional services for an enrollee undergoing a course of
15 continued treatment prescribed by a health care provider home health
16 care services following discharge from an inpatient hospital admission
17 pursuant to subdivision three of section forty-nine hundred three of
18 this article; or
19 (b) an adverse determination in which the health care provider
20 believes an immediate appeal is warranted except any retrospective
21 determination. Such process shall include mechanisms which facilitate
22 resolution of the appeal including but not limited to the sharing of
23 information from the enrollee's health care provider and the utilization
24 review agent by telephonic means or by facsimile. The utilization review
25 agent shall provide reasonable access to its clinical peer reviewer
26 within one business day of receiving notice of the taking of an expe-
27 dited appeal. Expedited appeals shall be determined within two business
28 days of receipt of necessary information to conduct such appeal. Expe-
29 dited appeals which do not result in a resolution satisfactory to the
30 appealing party may be further appealed through the standard appeal
31 process, or through the external appeal process pursuant to section
32 forty-nine hundred fourteen of this article as applicable. Provided
33 that the insured or the insured's health care provider notifies the
34 utilization review agent of its intent to file an external appeal imme-
35 diately upon receipt of an appeal determination and a request for an
36 expedited external appeal for treatment of chemical dependence or
37 substance use disorder and all necessary information is submitted within
38 twenty-four hours of receipt of an appeal determination, a utilization
39 review agent shall not deny, on the basis of medical necessity or lack
40 of prior authorization, coverage for such treatment while a determi-
41 nation by the external review agent is pending.
42 § 10. The superintendent of the department of financial services shall
43 select a random sampling of chemical dependence or substance use disor-
44 der treatment coverage determinations and provide an analysis of whether
45 or not such determinations are in compliance with the criteria estab-
46 lished in this act and report its finding to the governor, the temporary
47 president of the senate, and speaker of the assembly, the chairs of the
48 senate and assembly insurance committees, and the chairs of the senate
49 and assembly health committees no later than December 31, 2015.
50 § 11. 1. Within thirty days of the effective date of this act, the
51 commissioner of the office of alcoholism and substance abuse services,
52 superintendent of the department of financial services, and the commis-
53 sioner of health, shall jointly convene a workgroup to study and make
54 recommendations on improving access to and availability of chemical
55 dependence or substance use disorder treatment services in the state.
56 The workgroup shall be co-chaired by such commissioners and superinten-
A. 9943--B 7
1 dent, and shall also include, but not be limited to, representatives of
2 health care providers, insurers, additional professionals, individuals
3 and families who have been affected by addiction. The workgroup shall
4 include, but not be limited to, a review of the following:
5 a. Identifying barriers to obtaining necessary chemical dependence or
6 substance use disorder treatment services for across the state;
7 b. Recommendations for increasing access to and availability of chemi-
8 cal dependence or substance use disorder treatment services in the
9 state, including underserved areas of the state;
10 c. Identifying best clinical practices for chemical dependence or
11 substance use disorder treatment services;
12 d. A review of current insurance coverage requirements and recommenda-
13 tions for improving insurance coverage for chemical dependence or
14 substance use disorder and dependency treatment;
15 e. Recommendations for improving state agency communication and
16 collaboration relating to chemical dependence or substance use disorder
17 treatment services in the state;
18 f. Resources for affected individuals and families who are having
19 difficulties obtaining necessary chemical dependence or substance use
20 disorder treatment services; and
21 g. Methods for developing quality standards to measure the performance
22 of chemical dependence or substance use disorder treatment facilities in
23 the state.
24 2. The workgroup shall submit a report of its findings and recommenda-
25 tions to the governor, the temporary president of the senate, the speak-
26 er of the assembly, the chairs of the senate and assembly insurance
27 committees, and the chairs of the senate and assembly health committees
28 no later than December 31, 2015.
29 § 12. This act shall take effect January 1, 2015; provided, however,
30 that sections one through nine of this act shall apply to all policies
31 and contracts issued, delivered, renewed, modified, altered, or amended
32 after such date.
