Relates to insurance coverage for substance abuse disorder; requires health plans to use a health care provider who specializes in behavioral health or substance use disorder treatment to supervise and oversee the medical management decisions relating to substance abuse treatment.
TITLE OF BILL: An act to amend the insurance law, in relation to requiring health insurance coverage for substance abuse disorder treatment services and creating a workgroup to study and make recommendations
PURPOSE: This legislation clarifies that health insurance coverage must provide for substance abuse disorder treatment services improves the utilization review process for determining such insurance coverage and requires insurers to continue to provide coverage throughout the entire appeals process.
SUMMARY OF PROVISIONS: Section one amends the insurance law by adding a new section 3242 entitled coverage for substance abuse disorder. It clarifies that health plans shall include specific coverage for drug and alcohol abuse and dependency treatment services pursuant to the federal Mental Health and Parity Act of 2008 and applicable state statutes, It also requires a health plan to use a health care provider who specializes in substance abuse disorder treatment when conducting medical management or utilization review and utilizes only clinical review criteria contained in the American Society of Addiction Medicine's Patient Placement Criteria or a similar criteria deemed appropriate and approved by OASAS in consultation with DFS and DOH. This section also requires all internal and external appeals to be conducted on an expedited basis and health plans to provide coverage for substance abuse services until all appeals, both internal and external, have been exhausted
Section 2 creates a workgroup to study and make recommendations on improving access to and availability of substance abuse and dependency treatment services. The workgroup shall submit a report by December 31, 2014
JUSTIFICATION: The New York State Senate Heroin and Opioid Task Force has held hearings throughout the state to discuss the rise in the use of heroin and other opioids in New York State and to develop recommendations for treating and preventing addiction. At each of these hearings, the issue of health insurance coverage has been at the forefront This legislation will improve access to care by ensuring that decisions regarding treatment are strengthened and standardized and that they are made by medical doctors who specialize in substance abuse, Further, the legislation also ensures that individuals requiring treatment have access to an expedited appeals process and that they are not denied care while the appeals process is underway The legislation also establishes a workgroup to be convened jointly with OASAS, DFS and DOH in order to study and develop recommendations on improving access to and availability of substance abuse and dependency treatment services.
LEGISLATIVE HISTORY: New bill.
FISCAL IMPLICATIONS: None.
EFFECTIVE DATE: Immediately.
STATE OF NEW YORK ________________________________________________________________________ 7662 IN SENATE May 23, 2014 ___________Introduced by Sens. SEWARD, HANNON, MARTINS, RITCHIE, BOYLE, BALL, BONA- CIC, CARLUCCI, FELDER, GALLIVAN, GOLDEN, GRIFFO, LANZA, LARKIN, LITTLE, MARCELLINO, MARCHIONE, MAZIARZ, NOZZOLIO, O'MARA, RANZENHOFER, ROBACH, SAVINO, VALESKY, YOUNG -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law, in relation to requiring health insurance coverage for substance abuse disorder treatment services and creating a workgroup to study and make recommendations THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. The insurance law is amended by adding a new section 3242 to read as follows: S 3242. COVERAGE FOR SUBSTANCE ABUSE DISORDER. (A) (1) EVERY POLICY DELIVERED OR ISSUED FOR DELIVERY BY A HEALTH PLAN IN THIS STATE WHICH PROVIDES MEDICAL, MAJOR MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE FOR DRUG AND ALCOHOL ABUSE AND DEPENDEN- CY TREATMENT SERVICES PURSUANT TO THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008, AND APPLICABLE STATE STATUTES WHICH REQUIRES PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND TREATMENT. (2) DETERMINATION OF COVERAGE FOR SUBSTANCE ABUSE OR DEPENDENCY TREAT- MENT SERVICES BY A HEALTH PLAN SHALL BE MADE THROUGH A MEDICAL MANAGE- MENT REVIEW PROCESS WHICH: (A) UTILIZES A HEALTH CARE PROVIDER WHO SPECIALIZES IN SUBSTANCE USE DISORDER; AND (B) UTILIZES ONLY CLINICAL REVIEW CRITERIA CONTAINED IN THE AMERICAN SOCIETY OF ADDICTION MEDICINE'S PATIENT PLACEMENT CRITERIA OR ANOTHER CARE CRITERIA OR COMPENDIA DEEMED APPROPRIATE AND APPROVED FOR SUCH USE BY THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMISSIONER OF HEALTH AND THE SUPERINTENDENT OF THE DEPARTMENT OF FINANCIAL SERVICES. (3) THE LOCATION OF COVERED TREATMENT PURSUANT TO THIS SECTION SHALL BE SUBJECT TO THE INSURER'S REQUIREMENTS RELATING TO THE USE OF PARTIC-EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. S LBD15361-02-4 S. 7662 2
IPATING PROVIDERS, INCLUDING THOSE PROVIDERS LOCATED OUTSIDE OF THE STATE. (B) WHERE AN INSURED'S TREATING HEALTHCARE PROVIDER DETERMINES THAT A DELAY IN PROVIDING CARE OR TREATMENT RELATING TO A SUBSTANCE ABUSE DISORDER WOULD POSE A SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE INSURED, ALL INTERNAL AND EXTERNAL APPEALS OF UTILIZATION REVIEW DETER- MINATIONS SHALL BE CONDUCTED ON AN EXPEDITED BASIS, AS SET FORTH IN SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS CHAP- TER AND IN PARAGRAPH THREE OF SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS CHAPTER. (C) IN THE EVENT OF AN ADVERSE DETERMINATION FOR SUBSTANCE ABUSE OR DEPENDENCY TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE COVERAGE FOR ALL SUCH SERVICES UNTIL THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES THE HEALTH PLAN THAT HE OR SHE HAS DECIDED TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. (D) FOR PURPOSES OF THIS SECTION: (1) "SUBSTANCE ABUSE OR DEPENDENCY TREATMENT SERVICES" SHALL INCLUDE, BUT NOT BE LIMITED TO, HOSPITAL AND NON-HOSPITAL BASED DETOXIFICATION, INCLUDING MEDICALLY MANAGED, MEDICALLY SUPERVISED AND MEDICALLY MONITORED WITHDRAWAL, INPATIENT AND INTENSIVE RESIDENTIAL REHABILITATION, AND INTENSIVE AND ROUTINE OUTPA- TIENT TREATMENT; AND (2) "HEALTH PLAN" SHALL MEAN AN INSURER LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE SUBJECT TO ARTICLE FORTY-TWO OF THIS CHAPTER; A CORPO- RATION ORGANIZED PURSUANT TO ARTICLE FORTY-THREE OF THIS CHAPTER; A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER; A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW; OR A STUDENT HEALTH PLAN ESTABLISHED OR MAINTAINED PURSUANT TO SECTION ONE THOUSAND ONE HUNDRED TWENTY-FOUR OF THIS CHAPTER. S 2. 1. Within thirty days of the effective date of this act, the commissioner of the office of alcoholism and substance abuse services, superintendent of the department of financial services, and the commis- sioner of health, shall jointly convene a workgroup to study and make recommendations on improving access to and availability of substance abuse and dependency treatment services in the state. The workgroup shall be co-chaired by such commissioners and superintendent, and shall include, but not be limited to, a review of the following: a. Identifying barriers to obtaining necessary substance abuse treat- ment services for across the state; b. Recommendations for increasing access to and availability of substance abuse treatment services in the state, including underserved areas of the state; c. Identifying best clinical practices for substance abuse treatment services; d. A review of current insurance coverage requirements and recommenda- tions for improving insurance coverage for substance abuse and dependen- cy treatment; e. Recommendations for improving state agency communication and collaboration relating to substance abuse treatment services in the state; and f. Resources for affected individuals and families who are having difficulties obtaining necessary substance abuse treatment services. 2. The workgroup shall submit a report of its findings and recommenda- tions to the governor, the temporary president of the senate, the speak- er of the assembly, the chairs of the senate and assembly insuranceS. 7662 3
committees, and the chairs of the senate and assembly health committees no later than December 31, 2014. S 3. This act shall take effect immediately.