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A01921 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         1921--A
 
                               2025-2026 Regular Sessions
 
                   IN ASSEMBLY
 
                                    January 14, 2025
                                       ___________
 
        Introduced  by  M.  of A. PAULIN, LEVENBERG -- read once and referred to
          the Committee on Insurance  --  committee  discharged,  bill  amended,
          ordered reprinted as amended and recommitted to said committee
 
        AN  ACT  to  amend the insurance law, in relation to providing insurance
          coverage for non-opioid treatment of chronic pain

          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 40 to read as follows:
     3    (40) (A) Every policy that provides medical, major medical, or similar
     4  comprehensive-type coverage that provides coverage for  pain  management
     5  services  shall  provide outpatient coverage for non-opioid treatment of
     6  chronic pain including  complementary  and  integrative  treatments  and
     7  non-opioid  drugs  approved  by the United States Food and Drug Adminis-
     8  tration (FDA) for the treatment of acute  or  chronic  pain.  Access  to
     9  non-opioid  treatment  shall  be  comparable  to  that  of other covered
    10  services. Coverage shall be comparable for services provided by licensed
    11  professionals.
    12    (B) Coverage under this subsection shall not apply financial  require-
    13  ments  or  treatment limitations to non-opioid treatment of chronic pain
    14  that are more restrictive than either of the following: the  predominant
    15  financial requirements and treatment limitations applied to substantial-
    16  ly  all  medical  benefits  covered  by  the contract; and the financial
    17  requirements and  treatment  limitations  applied  to  any  opioid-based
    18  treatment  of  chronic  pain.  Coverage  under  this paragraph shall not
    19  disadvantage or discourage any non-opioid drug approved  by  the  United
    20  States  Food  and Drug Administration (FDA) for the treatment of chronic
    21  or acute pain relative to any opioid drug for the treatment  of  chronic
    22  or  acute  pain,  where  impermissible  disadvantaging or discouragement
    23  includes, without limitation: designating any such non-opioid drug as  a
    24  non-preferred  drug  if  any  opioid or narcotic drug is designated as a
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD05350-02-5

        A. 1921--A                          2
 
     1  preferred drug; or  establishing  more  restrictive  or  more  extensive
     2  utilization  controls including, but not limited to, more restrictive or
     3  more extensive financial  requirements,  prior  authorization,  or  step
     4  therapy  requirements,  for such non-opioid drug than the least restric-
     5  tive or extensive utilization controls applicable to any such opioid  or
     6  narcotic drug.
     7    (C)  For the purposes of this paragraph the following terms shall have
     8  the following meanings:
     9    (i) "financial requirement" means  deductible,  co-payments,  co-insu-
    10  rance and out-of-pocket expenses;
    11    (ii)  "predominant"  means  that  a financial requirement or treatment
    12  limitation is the most common or frequent  of  such  type  of  limit  or
    13  requirement;
    14    (iii)  "treatment  limitation" means limits on the frequency of treat-
    15  ment, number of visits, days of coverage, or other similar limits on the
    16  scope or duration of treatment and includes  non-quantitative  treatment
    17  limitations  such as: medical management standards limiting or excluding
    18  benefits based on medical necessity, or based on whether  the  treatment
    19  is  experimental or investigational; standards for provider admission to
    20  participate in a network, including  reimbursement  rates;  methods  for
    21  determining usual, customary and reasonable charges; exclusions based on
    22  failure  to  complete  a  course of treatment; and restrictions based on
    23  geographic location, facility type, provider specialty, and other crite-
    24  ria that limit the scope or duration of benefits for  services  provided
    25  under the contract;
    26    (iv)  "chronic  pain" means pain that persists or recurs for more than
    27  three months; and
    28    (v) "acute pain" means pain whether resulting from disease, accidental
    29  or intentional trauma, or other causes that is  reasonably  expected  to
    30  last only a short period of time.
    31    § 2. Subsection (l) of section 3221 of the insurance law is amended by
    32  adding a new paragraph 23 to read as follows:
    33    (23) (A) Every insurer delivering a group or blanket policy or issuing
    34  a  group  or  blanket  policy  for  delivery in this state that provides
    35  coverage for pain management services shall provide outpatient  coverage
    36  for  non-opioid  treatment  of  chronic pain including complementary and
    37  integrative treatments and  non-opioid  drugs  approved  by  the  United
    38  States  Food  and Drug Administration (FDA) for the treatment of chronic
    39  or acute pain. Access to non-opioid treatment and drugs for  the  treat-
    40  ment  of  acute  or  chronic  pain  shall be comparable to that of other
    41  covered services. Coverage shall be comparable for services provided  by
    42  licensed professionals.
    43    (B)  Coverage under this subsection shall not apply financial require-
    44  ments or treatment limitations to non-opioid treatment of  chronic  pain
    45  that  are more restrictive than either of the following: the predominant
    46  financial requirements and treatment limitations applied to substantial-
    47  ly all medical benefits covered  by  the  contract;  and  the  financial
    48  requirements  and  treatment  limitations  applied  to  any opioid-based
    49  treatment of chronic pain.  Coverage  under  this  paragraph  shall  not
    50  disadvantage  or  discourage  any non-opioid drug approved by the United
    51  States Food and Drug Administration (FDA) for the treatment  of  chronic
    52  or  acute  pain relative to any opioid drug for the treatment of chronic
    53  or acute pain,  where  impermissible  disadvantaging  or  discouragement
    54  includes,  without limitation: designating any such non-opioid drug as a
    55  non-preferred drug if any opioid or narcotic drug  is  designated  as  a
    56  preferred  drug;  or  establishing  more  restrictive  or more extensive

        A. 1921--A                          3
 
     1  utilization controls including, but not limited to, more restrictive  or
     2  more  extensive  financial  requirements,  prior  authorization, or step
     3  therapy requirements, for such non-opioid drug than the  least  restric-
     4  tive  or extensive utilization controls applicable to any such opioid or
     5  narcotic drug.
     6    (C) For the purposes of this paragraph the following terms shall  have
     7  the following meanings:
     8    (i)  "financial  requirement"  means deductible, co-payments, co-insu-
     9  rance and out-of-pocket expenses;
    10    (ii) "predominant" means that a  financial  requirement  or  treatment
    11  limitation  is  the  most  common  or  frequent of such type of limit or
    12  requirement;
    13    (iii) "treatment limitation" means limits on the frequency  of  treat-
    14  ment, number of visits, days of coverage, or other similar limits on the
    15  scope  or  duration of treatment and includes non-quantitative treatment
    16  limitations such as: medical management standards limiting or  excluding
    17  benefits  based  on medical necessity, or based on whether the treatment
    18  is experimental or investigational; standards for provider admission  to
    19  participate  in  a  network,  including reimbursement rates; methods for
    20  determining usual, customary and reasonable charges; exclusions based on
    21  failure to complete a course of treatment;  and  restrictions  based  on
    22  geographic location, facility type, provider specialty, and other crite-
    23  ria  that  limit the scope or duration of benefits for services provided
    24  under the contract;
    25    (iv) "chronic pain" means pain that persists or recurs for  more  than
    26  three months; and
    27    (v) "acute pain" means pain whether resulting from disease, accidental
    28  or  intentional  trauma,  or other causes that is reasonably expected to
    29  last only a short period of time.
    30    § 3. Section 4303 of the insurance law is  amended  by  adding  a  new
    31  subsection (ww) to read as follows:
    32    (ww)  (1)  Every  contract  issued  by a hospital service corporation,
    33  health service corporation or medical expense indemnity corporation that
    34  includes coverage for pain management services shall provide  outpatient
    35  coverage for non-opioid treatment of chronic pain including complementa-
    36  ry  and  integrative  treatments,  and  non-opioid drugs approved by the
    37  United States Food and Drug Administration (FDA) for  the  treatment  of
    38  acute  or chronic pain. Access to non-opioid treatment shall be compara-
    39  ble to that of other covered services. Coverage shall be comparable  for
    40  services provided by licensed professionals.
    41    (2)  Coverage under this subsection shall not apply financial require-
    42  ments or treatment limitations to non-opioid treatment of  chronic  pain
    43  that  are more restrictive than either of the following: the predominant
    44  financial requirements and treatment limitations applied to substantial-
    45  ly all medical benefits covered  by  the  contract;  and  the  financial
    46  requirements  and  treatment  limitations  applied  to  any opioid-based
    47  treatment of chronic pain. Coverage  under  this  subsection  shall  not
    48  disadvantage  or  discourage  any non-opioid drug approved by the United
    49  States Food and Drug Administration (FDA) for the treatment  of  chronic
    50  or  acute  pain relative to any opioid drug for the treatment of chronic
    51  or acute pain,  where  impermissible  disadvantaging  or  discouragement
    52  includes, without limitation: designating any such non-opioid drug  as a
    53  non-preferred  drug  if  any  opioid or narcotic drug is designated as a
    54  preferred drug; or  establishing  more  restrictive  or  more  extensive
    55  utilization  controls including, but not limited to, more restrictive or
    56  more extensive financial  requirements,  prior  authorization,  or  step

        A. 1921--A                          4
 
     1  therapy  requirements,  for such non-opioid drug than the least restric-
     2  tive or extensive utilization controls applicable to any such opioid  or
     3  narcotic drug.
     4    (3) For the purposes of this subsection the following terms shall have
     5  the following meanings:
     6    (A)  "financial  requirement"  means deductible, co-payments, co-insu-
     7  rance and out-of-pocket expenses;
     8    (B) "predominant" means that  a  financial  requirement  or  treatment
     9  limitation  is  the  most  common  or  frequent of such type of limit or
    10  requirement;
    11    (C) "treatment limitation" means limits on the frequency of treatment,
    12  number of visits, days of coverage, or other similar limits on the scope
    13  or duration of treatment and includes non-quantitative treatment limita-
    14  tions such as: medical management standards limiting or excluding  bene-
    15  fits  based  on  medical necessity, or based on whether the treatment is
    16  experimental or investigational; standards  for  provider  admission  to
    17  participate  in  a  network,  including reimbursement rates; methods for
    18  determining usual, customary and reasonable charges; exclusions based on
    19  failure to complete a course of treatment;  and  restrictions  based  on
    20  geographic location, facility type, provider specialty, and other crite-
    21  ria  that  limit the scope or duration of benefits for services provided
    22  under the contract;
    23    (D) "chronic pain" means pain that persists or recurs  for  more  than
    24  three months; and
    25    (E) "acute pain" means pain whether resulting from disease, accidental
    26  or  intentional  trauma,  or other causes that is reasonably expected to
    27  last only a short period of time.
    28    § 4. This act shall take effect the first day of January next succeed-
    29  ing the date on which it shall have become a law and shall apply to  all
    30  policies and contracts issued, renewed, modified, altered, or amended on
    31  or after such date.
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