STATE OF NEW YORK ________________________________________________________________________ 1921 2025-2026 Regular Sessions IN ASSEMBLY January 14, 2025 ___________ Introduced by M. of A. PAULIN -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to providing insurance coverage for 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. Access 7 to non-opioid treatment shall be comparable to that of other covered 8 services. Coverage shall be comparable for services provided by licensed 9 professionals. 10 (B) Coverage under this subsection shall not apply financial require- 11 ments or treatment limitations to non-opioid treatment of chronic pain 12 that are more restrictive than either of the following: the predominant 13 financial requirements and treatment limitations applied to substantial- 14 ly all medical benefits covered by the contract; and the financial 15 requirements and treatment limitations applied to any opioid-based 16 treatment of chronic pain. 17 (C) For the purposes of this paragraph the following terms shall have 18 the following meanings: 19 (i) "financial requirement" means deductible, co-payments, co-insu- 20 rance and out-of-pocket expenses; 21 (ii) "predominant" means that a financial requirement or treatment 22 limitation is the most common or frequent of such type of limit or 23 requirement; 24 (iii) "treatment limitation" means limits on the frequency of treat- 25 ment, number of visits, days of coverage, or other similar limits on the EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD05350-01-5
A. 1921 2 1 scope or duration of treatment and includes non-quantitative treatment 2 limitations such as: medical management standards limiting or excluding 3 benefits based on medical necessity, or based on whether the treatment 4 is experimental or investigational; standards for provider admission to 5 participate in a network, including reimbursement rates; methods for 6 determining usual, customary and reasonable charges; exclusions based on 7 failure to complete a course of treatment; and restrictions based on 8 geographic location, facility type, provider specialty, and other crite- 9 ria that limit the scope or duration of benefits for services provided 10 under the contract; and 11 (iv) "Chronic pain" means pain that persists or recurs for more than 12 three months. 13 § 2. Subsection (l) of section 3221 of the insurance law is amended by 14 adding a new paragraph 23 to read as follows: 15 (23) (A) Every insurer delivering a group or blanket policy or issuing 16 a group or blanket policy for delivery in this state that provides 17 coverage for pain management services shall provide outpatient coverage 18 for non-opioid treatment of chronic pain including complementary and 19 integrative treatments. Access to non-opioid treatment shall be compara- 20 ble to that of other covered services. Coverage shall be comparable for 21 services provided by licensed professionals. 22 (B) Coverage under this subsection shall not apply financial require- 23 ments or treatment limitations to non-opioid treatment of chronic pain 24 that are more restrictive than either of the following: the predominant 25 financial requirements and treatment limitations applied to substantial- 26 ly all medical benefits covered by the contract; and the financial 27 requirements and treatment limitations applied to any opioid-based 28 treatment of chronic pain. 29 (C) For the purposes of this paragraph the following terms shall have 30 the following meanings: 31 (i) "financial requirement" means deductible, co-payments, co-insu- 32 rance and out-of-pocket expenses; 33 (ii) "predominant" means that a financial requirement or treatment 34 limitation is the most common or frequent of such type of limit or 35 requirement; 36 (iii) "treatment limitation" means limits on the frequency of treat- 37 ment, number of visits, days of coverage, or other similar limits on the 38 scope or duration of treatment and includes non-quantitative treatment 39 limitations such as: medical management standards limiting or excluding 40 benefits based on medical necessity, or based on whether the treatment 41 is experimental or investigational; standards for provider admission to 42 participate in a network, including reimbursement rates; methods for 43 determining usual, customary and reasonable charges; exclusions based on 44 failure to complete a course of treatment; and restrictions based on 45 geographic location, facility type, provider specialty, and other crite- 46 ria that limit the scope or duration of benefits for services provided 47 under the contract; and 48 (iv) "chronic pain" means pain that persists or recurs for more than 49 three months. 50 § 3. Section 4303 of the insurance law is amended by adding a new 51 subsection (ww) to read as follows: 52 (ww) (1) Every contract issued by a hospital service corporation, 53 health service corporation or medical expense indemnity corporation that 54 includes coverage for pain management services shall provide outpatient 55 coverage for non-opioid treatment of chronic pain including complementa- 56 ry and integrative treatments. Access to non-opioid treatment shall be
A. 1921 3 1 comparable to that of other covered services. Coverage shall be compara- 2 ble for services provided by licensed professionals. 3 (2) Coverage under this subsection shall not apply financial require- 4 ments or treatment limitations to non-opioid treatment of chronic pain 5 that are more restrictive than either of the following: the predominant 6 financial requirements and treatment limitations applied to substantial- 7 ly all medical benefits covered by the contract; and the financial 8 requirements and treatment limitations applied to any opioid-based 9 treatment of chronic pain. 10 (3) For the purposes of this subsection the following terms shall have 11 the following meanings: 12 (A) "financial requirement" means deductible, co-payments, co-insu- 13 rance and out-of-pocket expenses; 14 (B) "predominant" means that a financial requirement or treatment 15 limitation is the most common or frequent of such type of limit or 16 requirement; 17 (C) "treatment limitation" means limits on the frequency of treatment, 18 number of visits, days of coverage, or other similar limits on the scope 19 or duration of treatment and includes non-quantitative treatment limita- 20 tions such as: medical management standards limiting or excluding bene- 21 fits based on medical necessity, or based on whether the treatment is 22 experimental or investigational; standards for provider admission to 23 participate in a network, including reimbursement rates; methods for 24 determining usual, customary and reasonable charges; exclusions based on 25 failure to complete a course of treatment; and restrictions based on 26 geographic location, facility type, provider specialty, and other crite- 27 ria that limit the scope or duration of benefits for services provided 28 under the contract; and 29 (D) "chronic pain" means pain that persists or recurs for more than 30 three months. 31 § 4. This act shall take effect the first day of January next succeed- 32 ing the date on which it shall have become a law and shall apply to all 33 policies and contracts issued, renewed, modified, altered, or amended on 34 or after such date.