STATE OF NEW YORK ________________________________________________________________________ 9341 IN ASSEMBLY March 6, 2024 ___________ Introduced by M. of A. GONZALEZ-ROJAS -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to certain cost sharing fees for outpatient treatment at a substance use treatment program The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subparagraph (E) of paragraph 31 of subsection (i) of 2 section 3216 of the insurance law, as amended by section 6 of subpart A 3 of part BB of chapter 57 of the laws of 2019, is amended and a new 4 subparagraph (J) is added to read as follows: 5 (E) This subparagraph shall apply to facilities in this state that are 6 licensed, certified or otherwise authorized by the office of [alcoholism 7 and substance abuse] addiction services and supports for the provision 8 of outpatient, intensive outpatient, outpatient rehabilitation and 9 opioid treatment that are participating in the insurer's provider 10 network. Coverage provided under this paragraph shall not be subject to 11 preauthorization. Coverage provided under this paragraph shall not be 12 subject to concurrent review for the first four weeks of continuous 13 treatment, not to exceed twenty-eight visits, provided the facility 14 notifies the insurer of both the start of treatment and the initial 15 treatment plan within two business days. The facility shall perform 16 clinical assessment of the patient at each visit, including periodic 17 consultation with the insurer at or just prior to the fourteenth day of 18 treatment to ensure that the facility is using the evidence-based and 19 peer reviewed clinical review tool utilized by the insurer which is 20 designated by the office of [alcoholism and substance abuse] addiction 21 services and supports and appropriate to the age of the patient, to 22 ensure that the outpatient treatment is medically necessary for the 23 patient. Any utilization review of the treatment provided under this 24 subparagraph may include a review of all services provided during such 25 outpatient treatment, including all services provided during the first 26 four weeks of continuous treatment, not to exceed twenty-eight visits, 27 of such outpatient treatment. Provided, however, the insurer shall only 28 deny coverage for any portion of the initial four weeks of continuous EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD11569-04-4
A. 9341 2 1 treatment, not to exceed twenty-eight visits, for outpatient treatment 2 on the basis that such treatment was not medically necessary if such 3 outpatient treatment was contrary to the evidence-based and peer 4 reviewed clinical review tool utilized by the insurer which is desig- 5 nated by the office of [alcoholism and substance abuse] addiction 6 services and supports. An insured shall only have financial responsibil- 7 ities as set out in subparagraph (J) of this paragraph and shall not 8 have any financial obligation to the facility for any treatment under 9 this subparagraph other than any [copayment,] coinsurance[, or deduct- 10 ible] otherwise required under the policy. 11 (J) For a substance use disorder outpatient treatment episode of care 12 by a provider licensed, certified or otherwise authorized by the office 13 of addiction services and supports, an insured shall only be responsible 14 for a cost sharing fee not to exceed five hundred dollars. An insurer 15 providing coverage under this paragraph shall be responsible for all 16 other financial obligations to the facility. An episode of care is 17 defined to include up to sixty visits with the same treatment provider. 18 § 2. Subparagraphs (C-1) and (E) of paragraph 7 of subsection (l) of 19 section 3221 of the insurance law, subparagraph (C-1) as added by 20 section 16 and subparagraph (E) as amended by section 17 of subpart A of 21 part BB of chapter 57 of the laws of 2019, are amended and a new subpar- 22 agraph (J) is added to read as follows: 23 (C-1) A large group policy that provides coverage under this paragraph 24 shall not impose [copayments or] coinsurance for outpatient substance 25 use disorder services that exceeds the [copayment or] coinsurance 26 imposed for a primary care office visit. [Provided that no greater than 27 one such copayment may be imposed for all services provided in a single 28 day by a facility licensed, certified or otherwise authorized by the 29 office of alcoholism and substance abuse services to provide outpatient 30 substance use disorder services] A large group policy that provides 31 coverage under this paragraph shall not impose copayments for outpatient 32 substance use disorder services. 33 (E) This subparagraph shall apply to facilities in this state that are 34 licensed, certified or otherwise authorized by the office of [alcoholism 35 and substance abuse] addiction services and supports for the provision 36 of outpatient, intensive outpatient, outpatient rehabilitation and 37 opioid treatment that are participating in the insurer's provider 38 network. Coverage provided under this paragraph shall not be subject to 39 preauthorization. Coverage provided under this paragraph shall not be 40 subject to concurrent review for the first four weeks of continuous 41 treatment, not to exceed twenty-eight visits, provided the facility 42 notifies the insurer of both the start of treatment and the initial 43 treatment plan within two business days. The facility shall perform 44 clinical assessment of the patient at each visit, including periodic 45 consultation with the insurer at or just prior to the fourteenth day of 46 treatment to ensure that the facility is using the evidence-based and 47 peer reviewed clinical review tool utilized by the insurer which is 48 designated by the office of [alcoholism and substance abuse] addiction 49 services and supports and appropriate to the age of the patient, to 50 ensure that the outpatient treatment is medically necessary for the 51 patient. Any utilization review of the treatment provided under this 52 subparagraph may include a review of all services provided during such 53 outpatient treatment, including all services provided during the first 54 four weeks of continuous treatment, not to exceed twenty-eight visits, 55 of such outpatient treatment. Provided, however, the insurer shall only 56 deny coverage for any portion of the initial four weeks of continuous
A. 9341 3 1 treatment, not to exceed twenty-eight visits, for outpatient treatment 2 on the basis that such treatment was not medically necessary if such 3 outpatient treatment was contrary to the evidence-based and peer 4 reviewed clinical review tool utilized by the insurer which is desig- 5 nated by the office of [alcoholism and substance abuse] addiction 6 services and supports. An insured shall only have financial responsibil- 7 ities as set out in subparagraph (J) of this paragraph and shall not 8 have any financial obligation to the facility for any treatment under 9 this subparagraph other than any [copayment,] coinsurance[, or deduct- 10 ible] otherwise required under the policy. 11 (J) For a substance use disorder outpatient treatment episode of care 12 by a provider licensed, certified or otherwise authorized by the office 13 of addiction services and supports, an insured shall only be responsible 14 for a cost sharing fee not to exceed five hundred dollars. An insurer 15 providing coverage under this paragraph shall be responsible for all 16 other financial obligations to the facility. An episode of care is 17 defined to include up to sixty visits with the same treatment provider. 18 § 3. Paragraphs 3-a and 5 of subsection (l) of section 4303 of the 19 insurance law, paragraph 3-a as added by section 27 and paragraph 5 as 20 amended by section 28 of subpart A of part BB of chapter 57 of the laws 21 of 2019, are amended and a new paragraph 10 is added to read as follows: 22 (3-a) A contract that provides large group coverage under this 23 subsection shall not impose [copayments or] coinsurance for outpatient 24 substance use disorder services that exceed the [copayment or] coinsu- 25 rance imposed for a primary care office visit. [Provided that no greater 26 than one such copayment may be imposed for all services provided in a 27 single day by a facility licensed, certified or otherwise authorized by 28 the office of alcoholism and substance abuse services to provide outpa- 29 tient substance use disorder services] A large group policy that 30 provides coverage under this paragraph shall not impose copayments for 31 outpatient substance use disorder services. 32 (5) This paragraph shall apply to facilities in this state that are 33 licensed, certified or otherwise authorized by the office of [alcoholism 34 and substance abuse] addiction services and supports for the provision 35 of outpatient, intensive outpatient, outpatient rehabilitation and 36 opioid treatment that are participating in the corporation's provider 37 network. Coverage provided under this subsection shall not be subject to 38 preauthorization. Coverage provided under this subsection shall not be 39 subject to concurrent review for the first four weeks of continuous 40 treatment, not to exceed twenty-eight visits, provided the facility 41 notifies the corporation of both the start of treatment and the initial 42 treatment plan within two business days. The facility shall perform 43 clinical assessment of the patient at each visit, including periodic 44 consultation with the corporation at or just prior to the fourteenth day 45 of treatment to ensure that the facility is using the evidence-based and 46 peer reviewed clinical review tool utilized by the corporation which is 47 designated by the office of [alcoholism and substance abuse] addiction 48 services and supports and appropriate to the age of the patient, to 49 ensure that the outpatient treatment is medically necessary for the 50 patient. Any utilization review of the treatment provided under this 51 paragraph may include a review of all services provided during such 52 outpatient treatment, including all services provided during the first 53 four weeks of continuous treatment, not to exceed twenty-eight visits, 54 of such outpatient treatment. Provided, however, the corporation shall 55 only deny coverage for any portion of the initial four weeks of contin- 56 uous treatment, not to exceed twenty-eight visits, for outpatient treat-
A. 9341 4 1 ment on the basis that such treatment was not medically necessary if 2 such outpatient treatment was contrary to the evidence-based and peer 3 reviewed clinical review tool utilized by the corporation which is 4 designated by the office of [alcoholism and substance abuse] addiction 5 services and supports. A subscriber shall only have financial responsi- 6 bilities as set out in paragraph ten of this subsection and shall not 7 have any financial obligation to the facility for any treatment under 8 this paragraph other than any [copayment,] coinsurance[, or deductible] 9 otherwise required under the contract. 10 (10) For a substance use disorder outpatient treatment episode of care 11 by a provider licensed, certified or otherwise authorized by the office 12 of addiction services and supports, an insured shall only be responsible 13 for a cost sharing fee not to exceed five hundred dollars. An insurer 14 providing coverage under this paragraph shall be responsible for all 15 other financial obligations to the facility. An episode of care is 16 defined to include up to sixty visits with the same treatment provider. 17 § 4. This act shall take effect on the first of January next succeed- 18 ing the date on which it shall have become a law and shall apply to 19 policies and contracts issued, renewed, modified, altered or amended on 20 and after such date.