STATE OF NEW YORK ________________________________________________________________________ 7288--A 2023-2024 Regular Sessions IN SENATE May 19, 2023 ___________ Introduced by Sens. FERNANDEZ, KENNEDY, RYAN -- read twice and ordered printed, and when printed to be committed to the Committee on Insur- ance -- recommitted to the Committee on Insurance in accordance with Senate Rule 6, sec. 8 -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee 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 EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD11569-03-4
S. 7288--A 2 1 patient. Any utilization review of the treatment provided under this 2 subparagraph may include a review of all services provided during such 3 outpatient treatment, including all services provided during the first 4 four weeks of continuous treatment, not to exceed twenty-eight visits, 5 of such outpatient treatment. Provided, however, the insurer shall only 6 deny coverage for any portion of the initial four weeks of continuous 7 treatment, not to exceed twenty-eight visits, for outpatient treatment 8 on the basis that such treatment was not medically necessary if such 9 outpatient treatment was contrary to the evidence-based and peer 10 reviewed clinical review tool utilized by the insurer which is desig- 11 nated by the office of [alcoholism and substance abuse] addiction 12 services and supports. An insured shall only have financial responsibil- 13 ities as set out in subparagraph (J) of this paragraph and shall not 14 have any financial obligation to the facility for any treatment under 15 this subparagraph other than any [copayment,] coinsurance[, or deduct- 16 ible] otherwise required under the policy. 17 (J) For a substance use disorder outpatient treatment episode of care 18 by a provider licensed, certified or otherwise authorized by the office 19 of addiction services and supports, an insured shall only be responsible 20 for a cost sharing fee not to exceed five hundred dollars. An insurer 21 providing coverage under this paragraph shall be responsible for all 22 other financial obligations to the facility. An episode of care is 23 defined to include up to sixty visits with the same treatment provider. 24 § 2. Subparagraphs (C-1) and (E) of paragraph 7 of subsection (l) of 25 section 3221 of the insurance law, subparagraph (C-1) as added by 26 section 16 and subparagraph (E) as amended by section 17 of subpart A of 27 part BB of chapter 57 of the laws of 2019, are amended and a new subpar- 28 agraph (J) is added to read as follows: 29 (C-1) A large group policy that provides coverage under this paragraph 30 shall not impose [copayments or] coinsurance for outpatient substance 31 use disorder services that exceeds the [copayment or] coinsurance 32 imposed for a primary care office visit. [Provided that no greater than 33 one such copayment may be imposed for all services provided in a single 34 day by a facility licensed, certified or otherwise authorized by the 35 office of alcoholism and substance abuse services to provide outpatient 36 substance use disorder services] A large group policy that provides 37 coverage under this paragraph shall not impose copayments for outpatient 38 substance use disorder services. 39 (E) This subparagraph shall apply to facilities in this state that are 40 licensed, certified or otherwise authorized by the office of [alcoholism 41 and substance abuse] addiction services and supports for the provision 42 of outpatient, intensive outpatient, outpatient rehabilitation and 43 opioid treatment that are participating in the insurer's provider 44 network. Coverage provided under this paragraph shall not be subject to 45 preauthorization. Coverage provided under this paragraph shall not be 46 subject to concurrent review for the first four weeks of continuous 47 treatment, not to exceed twenty-eight visits, provided the facility 48 notifies the insurer of both the start of treatment and the initial 49 treatment plan within two business days. The facility shall perform 50 clinical assessment of the patient at each visit, including periodic 51 consultation with the insurer at or just prior to the fourteenth day of 52 treatment to ensure that the facility is using the evidence-based and 53 peer reviewed clinical review tool utilized by the insurer which is 54 designated by the office of [alcoholism and substance abuse] addiction 55 services and supports and appropriate to the age of the patient, to 56 ensure that the outpatient treatment is medically necessary for the
S. 7288--A 3 1 patient. Any utilization review of the treatment provided under this 2 subparagraph may include a review of all services provided during such 3 outpatient treatment, including all services provided during the first 4 four weeks of continuous treatment, not to exceed twenty-eight visits, 5 of such outpatient treatment. Provided, however, the insurer shall only 6 deny coverage for any portion of the initial four weeks of continuous 7 treatment, not to exceed twenty-eight visits, for outpatient treatment 8 on the basis that such treatment was not medically necessary if such 9 outpatient treatment was contrary to the evidence-based and peer 10 reviewed clinical review tool utilized by the insurer which is desig- 11 nated by the office of [alcoholism and substance abuse] addiction 12 services and supports. An insured shall only have financial responsibil- 13 ities as set out in subparagraph (J) of this paragraph and shall not 14 have any financial obligation to the facility for any treatment under 15 this subparagraph other than any [copayment,] coinsurance[, or deduct- 16 ible] otherwise required under the policy. 17 (J) For a substance use disorder outpatient treatment episode of care 18 by a provider licensed, certified or otherwise authorized by the office 19 of addiction services and supports, an insured shall only be responsible 20 for a cost sharing fee not to exceed five hundred dollars. An insurer 21 providing coverage under this paragraph shall be responsible for all 22 other financial obligations to the facility. An episode of care is 23 defined to include up to sixty visits with the same treatment provider. 24 § 3. Paragraphs 3-a and 5 of subsection (l) of section 4303 of the 25 insurance law, paragraph 3-a as added by section 27 and paragraph 5 as 26 amended by section 28 of subpart A of part BB of chapter 57 of the laws 27 of 2019, are amended and a new paragraph 10 is added to read as follows: 28 (3-a) A contract that provides large group coverage under this 29 subsection shall not impose [copayments or] coinsurance for outpatient 30 substance use disorder services that exceed the [copayment or] coinsu- 31 rance imposed for a primary care office visit. [Provided that no greater 32 than one such copayment may be imposed for all services provided in a 33 single day by a facility licensed, certified or otherwise authorized by 34 the office of alcoholism and substance abuse services to provide outpa- 35 tient substance use disorder services] A large group policy that 36 provides coverage under this paragraph shall not impose copayments for 37 outpatient substance use disorder services. 38 (5) This paragraph shall apply to facilities in this state that are 39 licensed, certified or otherwise authorized by the office of [alcoholism 40 and substance abuse] addiction services and supports for the provision 41 of outpatient, intensive outpatient, outpatient rehabilitation and 42 opioid treatment that are participating in the corporation's provider 43 network. Coverage provided under this subsection shall not be subject to 44 preauthorization. Coverage provided under this subsection shall not be 45 subject to concurrent review for the first four weeks of continuous 46 treatment, not to exceed twenty-eight visits, provided the facility 47 notifies the corporation of both the start of treatment and the initial 48 treatment plan within two business days. The facility shall perform 49 clinical assessment of the patient at each visit, including periodic 50 consultation with the corporation at or just prior to the fourteenth day 51 of treatment to ensure that the facility is using the evidence-based and 52 peer reviewed clinical review tool utilized by the corporation which is 53 designated by the office of [alcoholism and substance abuse] addiction 54 services and supports and appropriate to the age of the patient, to 55 ensure that the outpatient treatment is medically necessary for the 56 patient. Any utilization review of the treatment provided under this
S. 7288--A 4 1 paragraph may include a review of all services provided during such 2 outpatient treatment, including all services provided during the first 3 four weeks of continuous treatment, not to exceed twenty-eight visits, 4 of such outpatient treatment. Provided, however, the corporation shall 5 only deny coverage for any portion of the initial four weeks of contin- 6 uous treatment, not to exceed twenty-eight visits, for outpatient treat- 7 ment on the basis that such treatment was not medically necessary if 8 such outpatient treatment was contrary to the evidence-based and peer 9 reviewed clinical review tool utilized by the corporation which is 10 designated by the office of [alcoholism and substance abuse] addiction 11 services and supports. A subscriber shall only have financial responsi- 12 bilities as set out in paragraph ten of this subsection and shall not 13 have any financial obligation to the facility for any treatment under 14 this paragraph other than any [copayment,] coinsurance[, or deductible] 15 otherwise required under the contract. 16 (10) For a substance use disorder outpatient treatment episode of care 17 by a provider licensed, certified or otherwise authorized by the office 18 of addiction services and supports, an insured shall only be responsible 19 for a cost sharing fee not to exceed five hundred dollars. An insurer 20 providing coverage under this paragraph shall be responsible for all 21 other financial obligations to the facility. An episode of care is 22 defined to include up to sixty visits with the same treatment provider. 23 § 4. This act shall take effect on the first of January next succeed- 24 ing the date on which it shall have become a law and shall apply to 25 policies and contracts issued, renewed, modified, altered or amended on 26 and after such date.