NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A6186A
SPONSOR: Gunther TITLE OF BILL: An act to amend the insurance law, in relation to
mental health and substance use disorder parity reporting; and to repeal
certain provisions of such law relating thereto
PURPOSE OR GENERAL IDEA OF BILL:
The purpose of the bill is to require insurers and health plans to
submit certain data to the Department of Financial Services and the
Commissioner of Health, as a way of measuring compliance with federal
and state mental health and substance abuse parity laws. The data will
be used by the Department of Financial Services to prepare an annual
Mental Health Parity report as part of the annual Consumer Guide.
SUMMARY OF SPECIFIC PROVISIONS:
Creates new § 343 of the Insurance Law to require the submission of a
mental health and substance use disorder parity report to the Department
of Financial Services.
JUSTIFICATION:
Ensuring New Yorkers have access to care and treatment for mental
illness and substance abuse disorders is critical and is the reason New
York enacted one of the strongest mental health parity laws in the
nation (Timothy's Law) in 2006. New York reaffirmed its commitment to
mental health parity when Timothy's Law was made permanent in 2009.
Although mental health parity has been the law of the land on the feder-
al and state level for a number of years now, the five settlements the
New York State Attorney General has reached over the last two years with
managed behavioral health companies and health plans or subcontractors
for noncompliance is a reminder of the challenges that remain to ensure
that the law is properly implemented and enforced.
In one of the instances, the Attorney General found that an insurer,
through its behavioral health subcontractor issued 64 percent more
denials of coverage in mental health and substance abuse cases than in
care for physical health conditions requiring previously denied claims
to be submitted for review with potential for $31 million in restitu-
tion for 15,000 policyholders. In another, the Attorney General found an
insurer, through its behavioral subcontractor issued 40 percent more
denials for coverage of mental health and substance abuse care and
treatment. Furthermore, in one of the investigations, the Attorney
General found a health plan rejected inpatient addiction treatment twice
as often as inpatient treatment for physical health between 2011 and
2014 and in 2012 alone - the rate of denial was nearly seven times high-
er.
While such data raises serious concerns, the investigations found
further unequal treatment of mental health and substance abuse including
charging a higher co-payment for outpatient mental health visits
compared to outpatient primary care visits, sometimes twice as high.
Other findings included lack of coverage of residential treatment for
mental health and substance abuse treatment and adverse determination
letters that did not provide adequate information including the medical
necessity criteria used to deny treatment. In other cases, the Attorney
General found utilization review of mental health and substance abuse
treatment was more intensive and frequent as compared for other medical
conditions, which required providers to spend an inordinate amount of
time justifying necessary and life-saving treatment. An example, from
one of the settlements is one pertaining to a 14 year old with an eating
disorder who was receiving partial hospitalization until the behavioral
health subcontractor for the health plan denied additional days of
treatment. The settlement goes on state, "As result, the member had to
interrupt treatment while an appeal was lodged on her behalf, exacerbat-
ing the symptoms of her illness, and causing her and her family extreme
emotional distress."
Other states have enacted statutes requiring insurers and health plans
to submit data as a mechanism for measuring implementation and compli-
ance with federal and state parity laws. It is time New York do the same
to provide the public and stakeholders with an annual analysis that will
provide critical insight into the following:
(A) coverage for mental health and substance abuse services, (B) the
adequacy of coverage for mental health and substance abuse conditions,
(C) the adequacy of mental health and substance abuse health care
provider networks, and (D) the rate of denials for treatment , prior
authorization requests, and utilization review for mental health and
substance abuse as compared to other medical care.
This legislation is needed to assure that New York achieves the full
implementation of the parity laws, while also working to reduce the
stigma surrounding mental illness and substance abuse, which in and of
itself can be one of the most prohibitive barriers for the nearly one in
ten individuals who have diagnosable mental health or substance abuse
condition in any given year. At time a when many of New York's communi-
ties are gripped be an epidemic tied to heroin and abuse of prescription
medications, it is imperative we have data that is publicly available
measuring compliance with the laws aimed at assuring access to care and
treatment.
PRIOR LEGISLATIVE HISTORY:
S. 7988 Referred to Insurance Committee
FISCAL IMPLICATIONS:
None
EFFECTIVE DATE:
Immediate.
STATE OF NEW YORK
________________________________________________________________________
6186--A
2019-2020 Regular Sessions
IN ASSEMBLY
February 28, 2019
___________
Introduced by M. of A. GUNTHER -- read once and referred to the Commit-
tee on Insurance -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee
AN ACT to amend the insurance law, in relation to mental health and
substance use disorder parity reporting; and to repeal certain
provisions of such law relating thereto
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subsection (c-1) of section 210 of the insurance law, as
2 amended by a chapter of the laws of 2018 amending the insurance law
3 relating to establishing the mental health and substance use disorder
4 parity report act, as proposed in legislative bills numbers S. 1156-C
5 and A. 3694-C, is REPEALED.
6 § 2. The insurance law is amended by adding a new section 343 to read
7 as follows:
8 § 343. Mental health and substance use disorder parity report. (a)
9 Beginning July first, two thousand nineteen and every two years there-
10 after, each insurer providing managed care products, individual compre-
11 hensive accident and health insurance or group or blanket comprehensive
12 accident and health insurance, each corporation organized pursuant to
13 article forty-three of this chapter providing comprehensive health
14 insurance and each entity licensed pursuant to article forty-four of the
15 public health law providing comprehensive health service plans shall
16 submit to the superintendent, in a form and manner prescribed by the
17 superintendent, a report detailing the entity's compliance with federal
18 and state mental health and substance use disorder parity laws based on
19 the entity's record during the preceding two calendar years. The super-
20 intendent shall publish on the department's website on or before October
21 first, two thousand nineteen, and every two years thereafter, the
22 reports submitted pursuant to this section.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD10356-02-9
A. 6186--A 2
1 (b) Each person required to submit a report under this section shall
2 include in the report the following information:
3 (1) Rates of utilization review for mental health and substance use
4 disorder claims as compared to medical and surgical claims, including
5 rates of approval and denial, categorized by benefits provided under the
6 following classifications: inpatient in-network, inpatient out-of-net-
7 work, outpatient in-network, outpatient out-of-network, emergency care,
8 and prescription drugs;
9 (2) The number of prior or concurrent authorization requests for
10 mental health services and for substance use disorder services and the
11 number of denials for such requests, compared with the number of prior
12 or concurrent authorization requests for medical and surgical services
13 and the number of denials for such requests, categorized by the same
14 classifications identified in paragraph one of this subsection;
15 (3) The rates of appeals of adverse determinations, including the
16 rates of adverse determinations upheld and overturned, for mental health
17 claims and substance use disorder claims compared with the rates of
18 appeals of adverse determinations, including the rates of adverse deter-
19 minations upheld and overturned, for medical and surgical claims;
20 (4) The percentage of claims paid for in-network mental health
21 services and for substance use disorder services compared with the
22 percentage of claims paid for in-network medical and surgical services
23 and the percentage of claims paid for out-of-network mental health
24 services and substance use disorder services compared with the percent-
25 age of claims paid for out-of-network medical and surgical services;
26 (5) The number of behavioral health advocates, pursuant to an agree-
27 ment with the office of the attorney general if applicable, or staff
28 available to assist policyholders with mental health benefits and
29 substance use disorder benefits;
30 (6) A comparison of the cost sharing requirements including but not
31 limited to co-pays and coinsurance, and the benefit limitations includ-
32 ing limitations on the scope and duration of coverage, for medical and
33 surgical services, and mental health services and substance use disorder
34 services for coverage in the individual, small group, and large group
35 markets, provided that the comparison captures at least seventy-five
36 percent of a company's enrollees in each market;
37 (7) The number by type of providers licensed to practice in this state
38 that provide services for the treatment and diagnosis of substance use
39 disorder who are in-network, and the number by type of providers
40 licensed to practice in this state that provide services for the diagno-
41 sis and treatment of mental, nervous or emotional disorders and
42 ailments, however defined in a company's policy, who are in-network;
43 (8) The percentage of providers of services for the treatment and
44 diagnosis of substance use disorder who remained participating provid-
45 ers, and the percentage of providers of services for the diagnosis and
46 treatment of mental, nervous or emotional disorders and ailments, howev-
47 er defined in a company's policy, who remained participating providers;
48 and
49 (9) Any other data, information, or metric the superintendent deems
50 necessary or useful to measure compliance with mental health and
51 substance use disorder parity including, but not limited to an evalu-
52 ation and assessment of: (i) the adequacy of the company's in-network
53 mental health services and substance use disorder provider panels pursu-
54 ant to provisions of the insurance law and public health law; and (ii)
55 the company's reimbursement for in-network and out-of-network mental
56 health services and substance use disorder services as compared to the
A. 6186--A 3
1 reimbursement for in-network and out-of-network medical and surgical
2 services.
3 § 3. Subsection (d) of section 210 of the insurance law, as amended by
4 a chapter of the laws of 2018 amending the insurance law relating to
5 establishing the mental health and substance use disorder parity report
6 act, as proposed in legislative bills numbers S. 1156-C and A. 3694-C,
7 is amended to read as follows:
8 (d) Health insurers and entities certified pursuant to article forty-
9 four of the public health law shall provide annually to the superinten-
10 dent and the commissioner of health, and the commissioner of health
11 shall provide to the superintendent, all of the information necessary
12 for the superintendent to produce the annual consumer guide[, including
13 the mental health and substance use disorder parity report]. In compil-
14 ing the guide, the superintendent shall make every effort to ensure that
15 the information is presented in a clear, understandable fashion which
16 facilitates comparisons among individual insurers and entities, and in a
17 format which lends itself to the widest possible distribution to consum-
18 ers. The superintendent shall either include the information from the
19 annual consumer guide in the consumer shopping guide required by
20 subsection (a) of section four thousand three hundred twenty-three of
21 this chapter or combine the two guides as long as consumers in the indi-
22 vidual market are provided with the information required by subsection
23 (a) of section four thousand three hundred twenty-three of this chapter.
24 § 4. This act shall take effect on the same date and in the same
25 manner as a chapter of the laws of 2018 amending the insurance law
26 relating to establishing the mental health and substance use disorder
27 parity report act, as proposed in legislative bills numbers S. 1156-C
28 and A. 3694-C, takes effect. Effective immediately, the amendment and/or
29 repeal of any rule or regulation necessary for the implementation of
30 this act on its effective date are authorized and directed to be made
31 and completed on or before such effective date.
