STATE OF NEW YORK ________________________________________________________________________ 3148 2025-2026 Regular Sessions IN ASSEMBLY January 23, 2025 ___________ Introduced by M. of A. GONZALEZ-ROJAS, HEVESI, SHIMSKY, BURDICK, DAVILA, GALLAGHER, LEVENBERG -- 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 (K) 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 EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD03320-01-5
A. 3148 2 1 outpatient treatment, including all services provided during the first 2 four weeks of continuous treatment, not to exceed twenty-eight visits, 3 of such outpatient treatment. Provided, however, the insurer shall only 4 deny coverage for any portion of the initial four weeks of continuous 5 treatment, not to exceed twenty-eight visits, for outpatient treatment 6 on the basis that such treatment was not medically necessary if such 7 outpatient treatment was contrary to the evidence-based and peer 8 reviewed clinical review tool utilized by the insurer which is desig- 9 nated by the office of [alcoholism and substance abuse] addiction 10 services and supports. An insured shall only have financial responsibil- 11 ities as set out in subparagraph (K) of this paragraph and shall not 12 have any financial obligation to the facility for any treatment under 13 this subparagraph other than any [copayment,] coinsurance[, or deduct- 14 ible] otherwise required under the policy. 15 (K) For a substance use disorder outpatient treatment episode of care 16 by a provider licensed, certified or otherwise authorized by the office 17 of addiction services and supports, an insured shall only be responsible 18 for a cost sharing fee not to exceed five hundred dollars. An insurer 19 providing coverage under this paragraph shall be responsible for all 20 other financial obligations to the facility. An episode of care is 21 defined to include up to sixty visits with the same treatment provider. 22 § 2. Subparagraphs (C-1) and (E) of paragraph 7 of subsection (l) of 23 section 3221 of the insurance law, subparagraph (C-1) as added by 24 section 16 and subparagraph (E) as amended by section 17 of subpart A of 25 part BB of chapter 57 of the laws of 2019, are amended and a new subpar- 26 agraph (K) is added to read as follows: 27 (C-1) A large group policy that provides coverage under this paragraph 28 shall not impose [copayments or] coinsurance for outpatient substance 29 use disorder services that exceeds the [copayment or] coinsurance 30 imposed for a primary care office visit. [Provided that no greater than 31 one such copayment may be imposed for all services provided in a single 32 day by a facility licensed, certified or otherwise authorized by the 33 office of alcoholism and substance abuse services to provide outpatient 34 substance use disorder services] A large group policy that provides 35 coverage under this paragraph shall not impose copayments for outpatient 36 substance use disorder services. 37 (E) This subparagraph shall apply to facilities in this state that are 38 licensed, certified or otherwise authorized by the office of [alcoholism 39 and substance abuse] addiction services and supports for the provision 40 of outpatient, intensive outpatient, outpatient rehabilitation and 41 opioid treatment that are participating in the insurer's provider 42 network. Coverage provided under this paragraph shall not be subject to 43 preauthorization. Coverage provided under this paragraph shall not be 44 subject to concurrent review for the first four weeks of continuous 45 treatment, not to exceed twenty-eight visits, provided the facility 46 notifies the insurer of both the start of treatment and the initial 47 treatment plan within two business days. The facility shall perform 48 clinical assessment of the patient at each visit, including periodic 49 consultation with the insurer at or just prior to the fourteenth day of 50 treatment to ensure that the facility is using the evidence-based and 51 peer reviewed clinical review tool utilized by the insurer which is 52 designated by the office of [alcoholism and substance abuse] addiction 53 services and supports and appropriate to the age of the patient, to 54 ensure that the outpatient treatment is medically necessary for the 55 patient. Any utilization review of the treatment provided under this 56 subparagraph may include a review of all services provided during such
A. 3148 3 1 outpatient treatment, including all services provided during the first 2 four weeks of continuous treatment, not to exceed twenty-eight visits, 3 of such outpatient treatment. Provided, however, the insurer shall only 4 deny coverage for any portion of the initial four weeks of continuous 5 treatment, not to exceed twenty-eight visits, for outpatient treatment 6 on the basis that such treatment was not medically necessary if such 7 outpatient treatment was contrary to the evidence-based and peer 8 reviewed clinical review tool utilized by the insurer which is desig- 9 nated by the office of [alcoholism and substance abuse] addiction 10 services and supports. An insured shall only have financial responsibil- 11 ities as set out in subparagraph (K) of this paragraph and shall not 12 have any financial obligation to the facility for any treatment under 13 this subparagraph other than any [copayment,] coinsurance[, or deduct- 14 ible] otherwise required under the policy. 15 (K) For a substance use disorder outpatient treatment episode of care 16 by a provider licensed, certified or otherwise authorized by the office 17 of addiction services and supports, an insured shall only be responsible 18 for a cost sharing fee not to exceed five hundred dollars. An insurer 19 providing coverage under this paragraph shall be responsible for all 20 other financial obligations to the facility. An episode of care is 21 defined to include up to sixty visits with the same treatment provider. 22 § 3. Paragraphs 3-a and 5 of subsection (l) of section 4303 of the 23 insurance law, paragraph 3-a as added by section 27 and paragraph 5 as 24 amended by section 28 of subpart A of part BB of chapter 57 of the laws 25 of 2019, are amended and a new paragraph 11 is added to read as follows: 26 (3-a) A contract that provides large group coverage under this 27 subsection shall not impose [copayments or] coinsurance for outpatient 28 substance use disorder services that exceed the [copayment or] coinsu- 29 rance imposed for a primary care office visit. [Provided that no greater 30 than one such copayment may be imposed for all services provided in a 31 single day by a facility licensed, certified or otherwise authorized by 32 the office of alcoholism and substance abuse services to provide outpa- 33 tient substance use disorder services] A large group policy that 34 provides coverage under this paragraph shall not impose copayments for 35 outpatient substance use disorder services. 36 (5) This paragraph shall apply to facilities in this state that are 37 licensed, certified or otherwise authorized by the office of [alcoholism 38 and substance abuse] addiction services and supports for the provision 39 of outpatient, intensive outpatient, outpatient rehabilitation and 40 opioid treatment that are participating in the corporation's provider 41 network. Coverage provided under this subsection shall not be subject to 42 preauthorization. Coverage provided under this subsection shall not be 43 subject to concurrent review for the first four weeks of continuous 44 treatment, not to exceed twenty-eight visits, provided the facility 45 notifies the corporation of both the start of treatment and the initial 46 treatment plan within two business days. The facility shall perform 47 clinical assessment of the patient at each visit, including periodic 48 consultation with the corporation at or just prior to the fourteenth day 49 of treatment to ensure that the facility is using the evidence-based and 50 peer reviewed clinical review tool utilized by the corporation which is 51 designated by the office of [alcoholism and substance abuse] addiction 52 services and supports and appropriate to the age of the patient, to 53 ensure that the outpatient treatment is medically necessary for the 54 patient. Any utilization review of the treatment provided under this 55 paragraph may include a review of all services provided during such 56 outpatient treatment, including all services provided during the first
A. 3148 4 1 four weeks of continuous treatment, not to exceed twenty-eight visits, 2 of such outpatient treatment. Provided, however, the corporation shall 3 only deny coverage for any portion of the initial four weeks of contin- 4 uous treatment, not to exceed twenty-eight visits, for outpatient treat- 5 ment on the basis that such treatment was not medically necessary if 6 such outpatient treatment was contrary to the evidence-based and peer 7 reviewed clinical review tool utilized by the corporation which is 8 designated by the office of [alcoholism and substance abuse] addiction 9 services and supports. A subscriber shall only have financial responsi- 10 bilities as set out in paragraph eleven of this subsection and shall not 11 have any financial obligation to the facility for any treatment under 12 this paragraph other than any [copayment,] coinsurance[, or deductible] 13 otherwise required under the contract. 14 (11) For a substance use disorder outpatient treatment episode of care 15 by a provider licensed, certified or otherwise authorized by the office 16 of addiction services and supports, an insured shall only be responsible 17 for a cost sharing fee not to exceed five hundred dollars. An insurer 18 providing coverage under this paragraph shall be responsible for all 19 other financial obligations to the facility. An episode of care is 20 defined to include up to sixty visits with the same treatment provider. 21 § 4. This act shall take effect on the first of January next succeed- 22 ing the date on which it shall have become a law and shall apply to 23 policies and contracts issued, renewed, modified, altered or amended on 24 and after such date.