A07704 Summary:

BILL NOA07704
 
SAME ASNo Same As
 
SPONSORFernandez
 
COSPNSR
 
MLTSPNSR
 
Amd §§3216, 3221, 3224-a, 4303 & 109, Ins L
 
Relates to behavioral health parity; requires facilities to perform daily clinical review of a patient and consult periodically with the insurer regarding the patient's progress, course of treatment, and discharge plan; requires insurers to actively participate in facility-initiated periodic consultations prior to the patient's discharge; makes related provisions (Part A); provides that no policy shall require prior authorization for an initial or renewal prescription for drugs for the detoxification or maintenance of a substance use disorder; makes related provisions (Part B).
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A07704 Actions:

BILL NOA07704
 
05/20/2021referred to insurance
05/25/2021reported referred to codes
06/07/2021reported referred to ways and means
06/10/2021reported referred to rules
06/10/2021reported
06/10/2021rules report cal.778
06/10/2021ordered to third reading rules cal.778
06/10/2021passed assembly
06/10/2021delivered to senate
06/10/2021REFERRED TO RULES
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A07704 Committee Votes:

INSURANCE Chair:Cahill DATE:05/25/2021AYE/NAY:23/0 Action: Favorable refer to committee Codes
CahillAyeBlankenbushAye
CookAyeHawleyAye
PretlowAyeByrneAye
RiveraAyeSchmittAye
CymbrowitzAyePalmesanoAye
LavineAyeDiPietroAye
SteckAyeGandolfoExcused
DilanAye
HunterAye
NiouAye
RosenthalAye
SternAye
McDonaldAye
JacobsonAye
WilliamsAye
MeeksAye
ForrestExcused
AndersonAye

CODES Chair:Dinowitz DATE:06/07/2021AYE/NAY:22/0 Action: Favorable refer to committee Ways and Means
DinowitzAyeMorinelloAye
PretlowAyeGiglioAye
CookAyeMontesanoAye
CymbrowitzAyeReillyAye
O'DonnellAyeMikulinAye
LavineAyeTannousisAye
PerryAye
AbinantiAye
WeprinAye
HevesiAye
FahyAye
SeawrightAye
RosenthalAye
WalkerAye
VanelAye
CruzAye

WAYS AND MEANS Chair:Weinstein DATE:06/10/2021AYE/NAY:32/2 Action: Favorable refer to committee Rules
WeinsteinAyeRaNay
GlickAyeFitzpatrickAye
NolanExcusedHawleyAye
PretlowAyeMontesanoAye
PerryAyeBlankenbushAye
ColtonAyeNorrisAye
CookAyeBrabenecAye
CahillAyePalmesanoAye
AubryAyeByrneNay
CusickAyeAshbyAye
BenedettoAye
WeprinAye
RodriguezAye
RamosAye
BraunsteinAye
McDonaldAye
RozicAye
DinowitzAye
JoynerAye
MagnarelliAye
ZebrowskiAye
BronsonAye
DilanAye
SeawrightAye
HyndmanAye

RULES Chair:Gottfried DATE:06/10/2021AYE/NAY:29/0 Action: Favorable
HeastieExcusedBarclayAye
GottfriedAyeHawleyAye
NolanExcusedGiglioAye
WeinsteinAyeBlankenbushAye
PretlowAyeNorrisAye
CookAyeMontesanoAye
GlickAyeRaAye
AubryAyeBrabenecAye
EnglebrightAye
DinowitzAye
ColtonAye
MagnarelliAye
PerryAye
PaulinAye
Peoples-StokesAye
BenedettoAye
LavineAye
LupardoAye
ZebrowskiAye
ThieleAye
BraunsteinAye
DickensAye
DavilaAye

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A07704 Floor Votes:

DATE:06/11/2021Assembly Vote  YEA/NAY: 148/1
AbbateYClarkYFrontusYLalorYPaulinYSillittiY
AbinantiYColtonYGalefYLavineYPeoples-StokesYSimonY
AndersonYConradYGallagherYLawlerYPerryYSimpsonY
AngelinoYCookYGallahanYLemondesYPheffer AmatoYSmithY
AshbyYCruzYGandolfoYLunsfordYPichardoYSmullenY
AubryYCusickYGiglio JAYLupardoYPretlowYSolagesY
BarclayYCymbrowitzYGiglio JMYMagnarelliYQuartYSteckY
BarnwellYDarlingYGlickYMamdaniYRaYSternY
BarrettYDavilaYGonzalez-RojasYManktelowYRajkumarYStirpeY
BarronYDe La RosaYGoodellYMcDonaldYRamosYTagueY
BenedettoYDeStefanoYGottfriedYMcDonoughYReillyYTannousisY
BichotteYDickensYGriffinYMcMahonYReyesYTaylorY
BlankenbushYDilanYGuntherYMeeksYRichardsonYThieleY
BrabenecYDinowitzYHawleyYMikulinYRivera J YVanelY
BraunsteinYDiPietroYHevesiYMiller B YRivera JDYWalczykY
BronsonYDursoYHunterYMiller MLYRodriguezYWalkerY
BrownYEichensteinYHyndmanYMitaynesYRosenthal D YWallaceY
BurdickYEnglebrightYJacksonYMontesanoNORosenthal L YWalshY
BurgosYEpsteinYJacobsonYMorinelloYRozicYWeinsteinY
BurkeYFahyYJean-PierreYNiouYSalkaYWeprinY
ButtenschonYFallYJensenYNolanERSantabarbaraYWilliamsY
ByrneYFernandezYJonesYNorrisYSayeghYWoernerY
ByrnesYFitzpatrickYJoynerYO'DonnellYSchmittYZebrowskiY
CahillYForrestYKellesYOtisYSeawrightYZinermanY
CarrollYFriendYKimYPalmesanoYSeptimoYMr. SpeakerY

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A07704 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A7704
 
SPONSOR: Fernandez
  TITLE OF BILL: An act to amend the insurance law, in relation to providing behavioral health parity (Part A); and to amend the insurance law, in relation to the authorization for certain drugs for the detoxification or mainte- nance of a substance use disorder (Part B)   PURPOSE OF THE BILL: The proposed legislation amends the Insurance Law to refine requirements for coverage of mental health and substance use disorder services to promote insurer compliance with New York State parity and prompt payment laws.   SUMMARY OF PROVISIONS: Part A, Sections 1-6 and 8-10 of the bill amend various provisions with- in sections 3216, 3221, and 4303 of the Insurance Law to prohibit preau- thorization and concurrent review for 14 days for licensed, certified, or otherwise authorized inpatient psychiatric hospital services for adults; clarify and reinforce the notice and periodic consultation requirements for providers and insurers during any periods where concur- rent review is prohibited for both mental health and substance use disorder coverage; and require insurer compliance with the prompt pay law for claims submitted for dates of services occurring while concur- rent review is prohibited. Part A, Section 7 of the bill amend section 3224-a of the Insurance Law to require insurer compliance with the timeframes established therein for claims submitted for dates of services occurring while preauthori- zation or concurrent review is prohibited. The provision clarifies that when preauthorization and concurrent review are prohibited an insurer may not determine that their obligation to pay a claim is not reasonably clear solely because they are prohibited from conducting utilization review. Part A, Sections 11 and 12 of the bill establish a private right of action for consumers to sue insurers for damages caused by parity law violations and the effective date of the act. Since the enactment of Timothy's Law, New York State and Federal Courts have foreclosed this opportunity for injured parties and regulatory enforcement for violations has stalled. See Bushell v. United Health Group, Inc. 2018 WL 1578167 (S.D.N.Y. 2018) Part B of the bill makes technical amendments to the insurance law which clarifies that policies which already have a prescription medication benefit must cover addiction medication and opioid overdose reversal medications without prior authorization.   JUSTIFICATION: Proposed revisions to Sections 3216, 3221, and 4303 of the Insurance Law are necessary to ensure providers and insurers communicate effectively to coordinate care and reduce over-utilization of services and the administrative burden associated with utilization review. Additionally, by prohibiting preauthorization and concurrent review for 14 days for licensed, certified, or otherwise authorized inpatient psychiatric hospital services for adults as well as children/youth, the proposed revisions will 'advance insurer parity compliance with respect to medical management for mental health services, align requirements appli- cable to mental health and substance use disorder coverage, and ensure timely access to medically necessary inpatient care for all New Yorkers with mental health conditions requiring an acute level of care. The proposed revisions to Section 3224-a of the Insurance Law are neces- sary to ensure that insurers comply with the prompt pay law in cases where preauthorization and concurrent review are prohibited by limiting insurer discretion to determine that their obligation to pay a claim is not reasonably clear solely because the insurer is prohibited from conducting utilization review.   PRIOR LEGISLATIVE HISTORY: New Bill.   FISCAL IMPLICATIONS: None.   EFFECTIVE DATE: Immediately.
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A07704 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          7704
 
                               2021-2022 Regular Sessions
 
                   IN ASSEMBLY
 
                                      May 20, 2021
                                       ___________
 
        Introduced  by M. of A. FERNANDEZ -- (at request of the Office of Mental
          Health) -- read once and referred to the Committee on Insurance
 
        AN ACT to amend the insurance law, in relation to  providing  behavioral
          health parity (Part A); and to amend the insurance law, in relation to
          the  authorization for certain drugs for the detoxification or mainte-
          nance of a substance use disorder (Part B)
 
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section  1.  This  act enacts into law components of legislation which
     2  are necessary to effectuate provisions relating  to  mental  health  and
     3  substance use disorder parity.  Each component is wholly contained with-
     4  in  a  Part identified as Parts A through B. The effective date for each
     5  particular provision contained within such Part is set forth in the last
     6  section of such Part. Any provision in any section  contained  within  a
     7  Part,  including  the  effective date of the Part, which makes reference
     8  to a section "of this act", when used in connection with that    partic-
     9  ular  component, shall  be  deemed  to mean and refer to the correspond-
    10  ing section of the Part in which it is found. Section three of this  act
    11  sets forth the general effective date of this act.
 
    12                                   PART A
 
    13    Section  1.  Subparagraph  (D)  of  paragraph  30 of subsection (i) of
    14  section 3216 of the insurance law, as amended by section 5 of subpart  A
    15  of  part  BB  of  chapter  57 of the laws of 2019, is amended to read as
    16  follows:
    17    (D) This subparagraph shall apply to facilities in this state that are
    18  licensed, certified or otherwise authorized by the office of [alcoholism
    19  and substance abuse services] addiction services and supports  that  are
    20  participating in the insurer's provider network. Coverage provided under
    21  this  paragraph  shall  not  be  subject  to  preauthorization. Coverage
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD09970-02-1

        A. 7704                             2
 
     1  provided under this paragraph shall also not be  subject  to  concurrent
     2  utilization  review  during the first twenty-eight days of the inpatient
     3  admission provided that the facility notifies the insurer  of  both  the
     4  admission and the initial treatment plan within two business days of the
     5  admission  on a standardized form developed by the department in consul-
     6  tation with the  department  of  health  and  the  office  of  addiction
     7  services  and supports. The facility shall perform daily clinical review
     8  of the patient[, including periodic] and consult periodically  with  the
     9  insurer  regarding  the  patient's  progress,  course  of treatment, and
    10  discharge plan. Periodic consultation with the insurer [at or just prior
    11  to] shall occur no later than the fourteenth day of treatment [to ensure
    12  that the facility is using the evidence-based and peer reviewed clinical
    13  review tool utilized by the insurer which is designated by the office of
    14  alcoholism and substance abuse services and appropriate to  the  age  of
    15  the  patient, to ensure that the inpatient treatment is medically neces-
    16  sary for the patient]. Prior to discharge, the  facility  shall  provide
    17  the  patient  and  the insurer with a written discharge plan which shall
    18  describe arrangements for additional services needed following discharge
    19  from the inpatient facility as determined using the  evidence-based  and
    20  peer-reviewed  clinical  review  tool  utilized  by the insurer which is
    21  designated by the office of [alcoholism and  substance  abuse  services]
    22  addiction  services and supports. Prior to discharge, the facility shall
    23  indicate to the insurer whether services included in the discharge  plan
    24  are  secured  or  determined  to be reasonably available. [Any] Insurers
    25  shall actively participate in facility-initiated periodic  consultations
    26  prior  to  the patient's discharge and except where the insurer fails to
    27  do so, any utilization review of treatment provided under this  subpara-
    28  graph  may  include  a review of all services provided during such inpa-
    29  tient treatment, including all services provided during the first  twen-
    30  ty-eight  days  of  such  inpatient  treatment.  Provided,  however, the
    31  insurer shall be required to process claims for the  provision  of  such
    32  services  within the timeframes established in subsection (a) of section
    33  three thousand two hundred twenty-four-a of this article and shall  only
    34  deny  coverage for any portion of the initial twenty-eight day inpatient
    35  treatment on the basis that such treatment was not  medically  necessary
    36  if  such inpatient treatment was contrary to the evidence-based and peer
    37  reviewed clinical review tool utilized by the insurer  which  is  desig-
    38  nated  by  the  office  of  [alcoholism  and  substance  abuse services]
    39  addiction services and supports. An insured shall not have any financial
    40  obligation to the facility for any  treatment  under  this  subparagraph
    41  other  than any copayment, coinsurance, or deductible otherwise required
    42  under the policy.
    43    § 2. Subparagraph (E) of paragraph 31 of  subsection  (i)  of  section
    44  3216  of the insurance law, as amended by section 6 of subpart A of part
    45  BB of chapter 57 of the laws of 2019, is amended to read as follows:
    46    (E) This subparagraph shall apply to facilities in this state that are
    47  licensed, certified or otherwise authorized by the office of [alcoholism
    48  and substance abuse services] addiction services and  supports  for  the
    49  provision of outpatient, intensive outpatient, outpatient rehabilitation
    50  and  opioid  treatment  that are participating in the insurer's provider
    51  network. Coverage provided under this paragraph shall not be subject  to
    52  preauthorization.  Coverage  provided  under this paragraph shall not be
    53  subject to concurrent review for the  first  four  weeks  of  continuous
    54  treatment,  not  to  exceed  twenty-eight  visits, provided the facility
    55  notifies the insurer of both the start  of  treatment  and  the  initial
    56  treatment plan within two business days on a standardized form developed

        A. 7704                             3
 
     1  by  the department in consultation with the department of health and the
     2  office of addiction services and supports. The  facility  shall  perform
     3  clinical  assessment  of the patient at each visit[, including periodic]
     4  and  consult  periodically  with  the  insurer  regarding  the patient's
     5  progress, course of treatment, and discharge plan. Periodic consultation
     6  with the insurer [at or just prior to] shall occur  no  later  than  the
     7  fourteenth  day  of  treatment [to ensure that the facility is using the
     8  evidence-based and peer reviewed clinical review tool  utilized  by  the
     9  insurer  which  is  designated by the office of alcoholism and substance
    10  abuse services and appropriate to the age of the patient, to ensure that
    11  the outpatient treatment is medically necessary for the patient].  [Any]
    12  Insurers  shall  actively  participate  in  facility-initiated  periodic
    13  consultations prior to the patient's  discharge  and  except  where  the
    14  insurer fails to do so, any utilization review of the treatment provided
    15  under  this  subparagraph  may include a review of all services provided
    16  during such outpatient treatment, including all services provided during
    17  the first four weeks of continuous treatment, not to exceed twenty-eight
    18  visits, of such outpatient treatment.  Provided,  however,  the  insurer
    19  shall  only  deny  coverage for any portion of the initial four weeks of
    20  continuous treatment, not to exceed twenty-eight visits, for  outpatient
    21  treatment  on  the basis that such treatment was not medically necessary
    22  if such outpatient treatment was contrary to the evidence-based and peer
    23  reviewed clinical review tool utilized by the insurer  which  is  desig-
    24  nated  by  the  office  of  [alcoholism  and  substance  abuse services]
    25  addiction services and supports.  An insured shall not have  any  finan-
    26  cial  obligation  to  the facility for any treatment under this subpara-
    27  graph other than any copayment,  coinsurance,  or  deductible  otherwise
    28  required under the policy.
    29    §  3.  Subparagraph  (G)  of paragraph 35 of subsection (i) of section
    30  3216 of the insurance law, as added by section 8 of subpart A of part BB
    31  of chapter 57 of the laws of 2019, is amended to read as follows:
    32    (G) This subparagraph shall apply to hospitals in this state that  are
    33  licensed,  certified  or  otherwise  authorized  by the office of mental
    34  health that are participating in the insurer's provider  network.  Where
    35  the  policy  provides coverage for inpatient hospital care, benefits for
    36  inpatient hospital care in a hospital as defined by subdivision  ten  of
    37  section 1.03 of the mental hygiene law [provided to individuals who have
    38  not  attained  the  age of eighteen] shall not be subject to preauthori-
    39  zation. Coverage provided under this  subparagraph  shall  also  not  be
    40  subject  to concurrent utilization review during the first fourteen days
    41  of the inpatient admission, provided the facility notifies  the  insurer
    42  of both the admission and the initial treatment plan within two business
    43  days of the admission on a standardized form developed by the department
    44  in  consultation  with the department of health and the office of mental
    45  health, performs daily clinical review of the patient, and [participates
    46  in periodic consultation with the insurer to ensure that the facility is
    47  using the evidence-based and  peer  reviewed  clinical  review  criteria
    48  utilized by the insurer which is approved by the office of mental health
    49  and  appropriate to the age of the patient, to ensure that the inpatient
    50  care is medically necessary for the patient] consults periodically  with
    51  the  insurer  regarding the patient's progress, course of treatment, and
    52  discharge plan. [All] Insurers shall actively participate  in  facility-
    53  initiated  periodic  consultations  prior to the patient's discharge and
    54  except where the insurer fails to do so, all  treatment  provided  under
    55  this  subparagraph may be reviewed retrospectively. Where care is denied
    56  retrospectively, an insured shall not have any financial  obligation  to

        A. 7704                             4
 
     1  the  facility  for  any treatment under this subparagraph other than any
     2  copayment, coinsurance, or deductible otherwise required under the poli-
     3  cy.
     4    § 4. Subparagraph (G) of paragraph 5 of subsection (l) of section 3221
     5  of  the insurance law, as added by section 14 of subpart A of part BB of
     6  chapter 57 of the laws of 2019, is amended to read as follows:
     7    (G) This subparagraph shall apply to hospitals in this state that  are
     8  licensed,  certified  or  otherwise  authorized  by the office of mental
     9  health that are participating in the insurer's provider  network.  Where
    10  the  policy  provides coverage for inpatient hospital care, benefits for
    11  inpatient hospital care in a hospital as defined by subdivision  ten  of
    12  section 1.03 of the mental hygiene law [provided to individuals who have
    13  not  attained  the  age of eighteen] shall not be subject to preauthori-
    14  zation. Coverage provided under this  subparagraph  shall  also  not  be
    15  subject  to concurrent utilization review during the first fourteen days
    16  of the inpatient admission, provided the facility notifies  the  insurer
    17  of both the admission and the initial treatment plan within two business
    18  days of the admission on a standardized form developed by the department
    19  in  consultation  with the department of health and the office of mental
    20  health, performs daily clinical review of the patient, and [participates
    21  in periodic consultation with the insurer to ensure that the facility is
    22  using the evidence-based and  peer  reviewed  clinical  review  criteria
    23  utilized by the insurer which is approved by the office of mental health
    24  and  appropriate to the age of the patient, to ensure that the inpatient
    25  care is medically necessary for the patient] consults periodically  with
    26  the  insurer  regarding the patient's progress, course of treatment, and
    27  discharge plan. [All] Insurers shall actively participate  in  facility-
    28  initiated  periodic  consultations  prior to the patient's discharge and
    29  except where the insurer fails to do so, all  treatment  provided  under
    30  this  subparagraph may be reviewed retrospectively. Where care is denied
    31  retrospectively, an insured shall not have any financial  obligation  to
    32  the  facility  for  any treatment under this subparagraph other than any
    33  copayment, coinsurance, or deductible otherwise required under the poli-
    34  cy.
    35    § 5. Subparagraph (D) of paragraph 6 of subsection (l) of section 3221
    36  of the insurance law, as amended by section 15 of subpart A of  part  BB
    37  of chapter 57 of the laws of 2019, is amended to read as follows:
    38    (D) This subparagraph shall apply to facilities in this state that are
    39  licensed, certified or otherwise authorized by the office of [alcoholism
    40  and  substance  abuse services] addiction services and supports that are
    41  participating in the insurer's provider network. Coverage provided under
    42  this paragraph  shall  not  be  subject  to  preauthorization.  Coverage
    43  provided  under  this  paragraph shall also not be subject to concurrent
    44  utilization review during the first twenty-eight days of  the  inpatient
    45  admission  provided  that  the facility notifies the insurer of both the
    46  admission and the initial treatment plan within two business days of the
    47  admission on a standardized form developed by the department in  consul-
    48  tation  with  the  department  of  health  and  the  office of addiction
    49  services and supports. The facility shall perform daily clinical  review
    50  of  the  patient[, including periodic] and consult periodically with the
    51  insurer regarding the  patient's  progress,  course  of  treatment,  and
    52  discharge plan. Periodic consultation with the insurer [at or just prior
    53  to] shall occur no later than the fourteenth day of treatment [to ensure
    54  that the facility is using the evidence-based and peer reviewed clinical
    55  review tool utilized by the insurer which is designated by the office of
    56  alcoholism  and  substance  abuse services and appropriate to the age of

        A. 7704                             5

     1  the patient, to ensure that the inpatient treatment is medically  neces-
     2  sary  for  the  patient]. Prior to discharge, the facility shall provide
     3  the patient and the insurer with a written discharge  plan  which  shall
     4  describe arrangements for additional services needed following discharge
     5  from  the  inpatient facility as determined using the evidence-based and
     6  peer-reviewed clinical review tool utilized  by  the  insurer  which  is
     7  designated  by  the  office of [alcoholism and substance abuse services]
     8  addiction services and supports. Prior to discharge, the facility  shall
     9  indicate  to the insurer whether services included in the discharge plan
    10  are secured or determined to be  reasonably  available.  [Any]  Insurers
    11  shall  actively participate in facility-initiated periodic consultations
    12  prior to the patient's discharge and except where the insurer  fails  to
    13  do  so, any utilization review of treatment provided under this subpara-
    14  graph may include a review of all services provided  during  such  inpa-
    15  tient  treatment, including all services provided during the first twen-
    16  ty-eight days  of  such  inpatient  treatment.  Provided,  however,  the
    17  insurer  shall  be  required to process claims for the provision of such
    18  services within the timeframes established in subsection (a) of  section
    19  three  thousand two hundred twenty-four-a of this article and shall only
    20  deny coverage for any portion of the initial twenty-eight day  inpatient
    21  treatment  on  the basis that such treatment was not medically necessary
    22  if such inpatient treatment was contrary to the evidence-based and  peer
    23  reviewed  clinical  review  tool utilized by the insurer which is desig-
    24  nated by  the  office  of  [alcoholism  and  substance  abuse  services]
    25  addiction services and supports. An insured shall not have any financial
    26  obligation  to  the  facility  for any treatment under this subparagraph
    27  other than any copayment, coinsurance, or deductible otherwise  required
    28  under the policy.
    29    § 6. Subparagraph (E) of paragraph 7 of subsection (l) of section 3221
    30  of  the  insurance law, as amended by section 17 of subpart A of part BB
    31  of chapter 57 of the laws of 2019, is amended to read as follows:
    32    (E) This subparagraph shall apply to facilities in this state that are
    33  licensed, certified or otherwise authorized by the office of [alcoholism
    34  and substance abuse services] addiction services and  supports  for  the
    35  provision of outpatient, intensive outpatient, outpatient rehabilitation
    36  and  opioid  treatment  that are participating in the insurer's provider
    37  network. Coverage provided under this paragraph shall not be subject  to
    38  preauthorization.  Coverage  provided  under this paragraph 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 insurer of both the start  of  treatment  and  the  initial
    42  treatment plan within two business days on a standardized form developed
    43  by  the department in consultation with the department of health and the
    44  office of addiction services and supports. The  facility  shall  perform
    45  clinical  assessment  of the patient at each visit[, including periodic]
    46  and consult  periodically  with  the  insurer  regarding  the  patient's
    47  progress, course of treatment, and discharge plan. Periodic consultation
    48  with  the  insurer  [at  or just prior to] shall occur no later than the
    49  fourteenth day of treatment [to ensure that the facility  is  using  the
    50  evidence-based  and  peer  reviewed clinical review tool utilized by the
    51  insurer which is designated by the office of  alcoholism  and  substance
    52  abuse services and appropriate to the age of the patient, to ensure that
    53  the  outpatient treatment is medically necessary for the patient]. [Any]
    54  Insurers  shall  actively  participate  in  facility-initiated  periodic
    55  consultations  prior  to  the  patient's  discharge and except where the
    56  insurer fails to do so, any utilization review of the treatment provided

        A. 7704                             6
 
     1  under this subparagraph may include a review of  all  services  provided
     2  during such outpatient treatment, including all services provided during
     3  the first four weeks of continuous treatment, not to exceed twenty-eight
     4  visits,  of  such  outpatient  treatment. Provided, however, the insurer
     5  shall only deny coverage for any portion of the initial  four  weeks  of
     6  continuous  treatment, not to exceed twenty-eight visits, for outpatient
     7  treatment on the basis that such treatment was not  medically  necessary
     8  if such outpatient treatment was contrary to the evidence-based and peer
     9  reviewed  clinical  review  tool utilized by the insurer which is desig-
    10  nated by  the  office  of  [alcoholism  and  substance  abuse  services]
    11  addiction  services  and supports.  An insured shall not have any finan-
    12  cial obligation to the facility for any treatment  under  this  subpara-
    13  graph  other  than  any  copayment, coinsurance, or deductible otherwise
    14  required under the policy.
    15    § 7. Subsection (a) of section 3224-a of the insurance law, as amended
    16  by chapter 237 of the laws of 2009, is amended to read as follows:
    17    (a) Except in a case where the obligation of an insurer or  an  organ-
    18  ization  or corporation licensed or certified pursuant to article forty-
    19  three or forty-seven of this chapter or article forty-four of the public
    20  health law to pay a claim submitted by a policyholder or person  covered
    21  under  such policy ("covered person") or make a payment to a health care
    22  provider is not reasonably clear, or when there is  a  reasonable  basis
    23  supported  by  specific  information  available for review by the super-
    24  intendent that such claim or bill for health care services rendered  was
    25  submitted  fraudulently,  such  insurer  or  organization or corporation
    26  shall pay the claim to a  policyholder  or  covered  person  or  make  a
    27  payment  to  a  health  care provider within thirty days of receipt of a
    28  claim or bill for services rendered that is transmitted via the internet
    29  or electronic mail, or forty-five days of receipt of a claim or bill for
    30  services rendered that is submitted by other means,  such  as  paper  or
    31  facsimile.  The obligation of an insurer or organization to make payment
    32  to a health care provider for mental health or  substance  use  disorder
    33  services  that  are not subject to preauthorization or concurrent review
    34  pursuant to sections three thousand two hundred sixteen, three  thousand
    35  two  hundred  twenty-one,  or  four thousand three hundred three of this
    36  chapter shall not be considered not reasonably clear solely because  the
    37  insurer  or  organization  intends to perform concurrent review for such
    38  services before or after the expiration of the timeframes established by
    39  this subsection.
    40    § 8. Paragraph 8 of subsection (g) of section 4303  of  the  insurance
    41  law, as added by section 23 of subpart A of part BB of chapter 57 of the
    42  laws of 2019, is amended to read as follows:
    43    (8)  This  paragraph  shall  apply to hospitals in this state that are
    44  licensed, certified or otherwise authorized  by  the  office  of  mental
    45  health  that are participating in the [corporation's] insurer's provider
    46  network. Where the contract provides  coverage  for  inpatient  hospital
    47  care,  benefits  for inpatient hospital care in a hospital as defined by
    48  subdivision ten of section 1.03 of the mental hygiene law  [provided  to
    49  individuals  who  have  not  attained  the age of eighteen] shall not be
    50  subject to preauthorization.  Coverage  provided  under  this  paragraph
    51  shall  also  not  be subject to concurrent utilization review during the
    52  first fourteen days of the inpatient admission,  provided  the  facility
    53  notifies the [corporation] insurer of both the admission and the initial
    54  treatment  plan within two business days of the admission on a standard-
    55  ized form developed by the department in consultation with  the  depart-
    56  ment  of health and the office of mental health, performs daily clinical

        A. 7704                             7
 
     1  review of the patient, and [participates in periodic  consultation  with
     2  the  corporation to ensure that the facility is using the evidence-based
     3  and peer reviewed clinical review criteria utilized by  the  corporation
     4  which  is approved by the office of mental health and appropriate to the
     5  age of the patient, to ensure  that  the  inpatient  care  is  medically
     6  necessary  for  the  patient]  consults  periodically  with  the insurer
     7  regarding the patient's progress, course  of  treatment,  and  discharge
     8  plan.    [All] Insurers shall actively participate in facility-initiated
     9  periodic consultations prior to the patient's discharge and except where
    10  the insurer fails to do so, all treatment provided under this  paragraph
    11  may  be  reviewed retrospectively. Where care is denied retrospectively,
    12  an insured shall not have any financial obligation to the  facility  for
    13  any  treatment  under  this  paragraph other than any copayment, coinsu-
    14  rance, or deductible otherwise required under the contract.
    15    § 9. Paragraph 4 of subsection (k) of section 4303  of  the  insurance
    16  law,  as  amended by section 26 of subpart A of part BB of chapter 57 of
    17  the laws of 2019, is amended to read as follows:
    18    (4) This paragraph shall apply to facilities in this  state  that  are
    19  licensed,  certified or otherwise authorized by the office of alcoholism
    20  and substance abuse services  that  are  participating  in  the  [corpo-
    21  ration's]  insurer's  provider  network.  Coverage  provided  under this
    22  subsection shall not be subject to preauthorization.  Coverage  provided
    23  under  this  subsection shall also not be subject to concurrent utiliza-
    24  tion review during the first twenty-eight days of the  inpatient  admis-
    25  sion  provided  that  the facility notifies the [corporation] insurer of
    26  both the admission and the initial treatment plan  within  two  business
    27  days of the admission on a standardized form developed by the department
    28  in  consultation  with  the  department  of  health  and  the  office of
    29  addiction services and supports. The facility shall perform daily  clin-
    30  ical  review  of  the  patient[,  including  periodic  consultation] and
    31  consult periodically with the insurer regarding the patient's  progress,
    32  course of treatment, and discharge plan.  Periodic consultation with the
    33  [corporation at or just prior to] insurer shall occur not later than the
    34  fourteenth  day  of  treatment [to ensure that the facility is using the
    35  evidence-based and peer reviewed clinical review tool  utilized  by  the
    36  corporation  which  is  designated  by  the  office  of  alcoholism  and
    37  substance abuse services and appropriate to the age of the  patient,  to
    38  ensure  that  the  inpatient  treatment  is  medically necessary for the
    39  patient]. Prior to discharge, the facility shall provide the patient and
    40  the [corporation] insurer with a  written  discharge  plan  which  shall
    41  describe arrangements for additional services needed following discharge
    42  from  the  inpatient facility as determined using the evidence-based and
    43  peer-reviewed clinical review tool utilized by the [corporation] insurer
    44  which is designated by the office of  [alcoholism  and  substance  abuse
    45  services]  addiction  services  and  supports.  Prior  to discharge, the
    46  facility shall indicate to the [corporation]  insurer  whether  services
    47  included  in  the discharge plan are secured or determined to be reason-
    48  ably available.  [Any] Insurers shall actively participate in  facility-
    49  initiated  periodic  consultations  prior to the patient's discharge and
    50  except where the insurer fails to  do  so,  any  utilization  review  of
    51  treatment  provided  under  this  paragraph  may include a review of all
    52  services  provided  during  such  inpatient  treatment,  including   all
    53  services  provided  during the first twenty-eight days of such inpatient
    54  treatment.  Provided,  however,  the  [corporation]  insurer  shall   be
    55  required to process claims for the provision of such services within the
    56  timeframes  established  in subsection (a) of section three thousand two

        A. 7704                             8

     1  hundred twenty-four-a of this chapter and shall only deny  coverage  for
     2  any  portion  of the initial twenty-eight day inpatient treatment on the
     3  basis that such treatment was not medically necessary if such  inpatient
     4  treatment  was contrary to the evidence-based and peer reviewed clinical
     5  review tool utilized by the [corporation] insurer which is designated by
     6  the office  of  [alcoholism  and  substance  abuse  services]  addiction
     7  services  and  supports.   An insured shall not have any financial obli-
     8  gation to the facility for any treatment under this paragraph other than
     9  any copayment, coinsurance, or deductible otherwise required  under  the
    10  contract.
    11    §  10.  Paragraph 5 of subsection (l) of section 4303 of the insurance
    12  law, as amended by section 28 of subpart A of part BB of chapter  57  of
    13  the laws of 2019, is amended to read as follows:
    14    (5)  This  paragraph  shall apply to facilities in this state that are
    15  licensed, certified or otherwise authorized by the office of [alcoholism
    16  and substance abuse services] addiction services and  supports  for  the
    17  provision of outpatient, intensive outpatient, outpatient rehabilitation
    18  and opioid treatment that are participating in the corporation's provid-
    19  er network. Coverage provided under this subsection shall not be subject
    20  to  preauthorization.  Coverage provided under this subsection shall not
    21  be subject to concurrent review for the first four weeks  of  continuous
    22  treatment,  not  to  exceed  twenty-eight  visits, provided the facility
    23  notifies the corporation of both the start of treatment and the  initial
    24  treatment plan within two business days on a standardized form developed
    25  by  the department in consultation with the department of health and the
    26  office of addiction services and supports. The  facility  shall  perform
    27  clinical  assessment  of the patient at each visit[, including periodic]
    28  and consult  periodically  with  the  insurer  regarding  the  patient's
    29  progress, course of treatment, and discharge plan. Periodic consultation
    30  with the corporation [at or just prior to] shall occur no later than the
    31  fourteenth  day  of  treatment [to ensure that the facility is using the
    32  evidence-based and peer reviewed clinical review tool  utilized  by  the
    33  corporation  which  is  designated  by  the  office  of  alcoholism  and
    34  substance abuse services and appropriate to the age of the  patient,  to
    35  ensure  that  the  outpatient  treatment  is medically necessary for the
    36  patient]. [Any] Insurers shall actively participate in facility-initiat-
    37  ed periodic consultations prior to the patient's  discharge  and  except
    38  where  the  insurer fails to do so, any utilization review of the treat-
    39  ment provided under this paragraph may include a review of all  services
    40  provided  during  such  outpatient  treatment,  including  all  services
    41  provided during the first four weeks of  continuous  treatment,  not  to
    42  exceed  twenty-eight  visits,  of such outpatient treatment.   Provided,
    43  however, the corporation shall only deny coverage for any portion of the
    44  initial four weeks of continuous treatment, not to  exceed  twenty-eight
    45  visits,  for  outpatient  treatment on the basis that such treatment was
    46  not medically necessary if such outpatient treatment was contrary to the
    47  evidence-based and peer reviewed clinical review tool  utilized  by  the
    48  corporation  which  is  designated  by  the  office  of  [alcoholism and
    49  substance abuse services] addiction services and supports. [A  subscrib-
    50  er]  An  insured shall not have any financial obligation to the facility
    51  for any treatment under this paragraph other than any copayment, coinsu-
    52  rance, or deductible otherwise required under the contract.
    53    § 11. Section 109 of the insurance law is  amended  by  adding  a  new
    54  subsection (e) to read as follows:
    55    (e)  In  addition to any right of action granted to the superintendent
    56  pursuant to this section, any person who has been injured by reason of a

        A. 7704                             9
 
     1  violation of paragraphs thirty, thirty-one, thirty-one-a and thirty-five
     2  of subsection (i) of section three thousand two hundred  sixteen,  para-
     3  graphs  five,  six,  seven,  seven-a  and  seven-b  of subsection (l) of
     4  section three thousand two hundred twenty-one, and subsections (g), (k),
     5  (l), (l-1) or (l-2) of section four thousand three hundred three of this
     6  chapter  by  an  insurer subject to article thirty-two or forty-three of
     7  this chapter may bring an action in his or her own name to  enjoin  such
     8  unlawful act or practice, an action to recover his or her actual damages
     9  or one thousand dollars, whichever is greater, or both such actions. The
    10  court  may,  in  its  discretion, award the prevailing plaintiff in such
    11  action an additional award not to exceed five thousand dollars,  if  the
    12  court  finds  the  defendant  willfully  violated the provisions of this
    13  section. The court may award reasonable attorneys' fees to a  prevailing
    14  plaintiff.
    15    § 12. This act shall take effect January 1, 2022.
 
    16                                   PART B
 
    17    Section  1.  Subparagraph  (A)  of paragraph 31-a of subsection (i) of
    18  section 3216 of the insurance law, as added by chapter 748 of  the  laws
    19  of 2019, is amended to read as follows:
    20    (A)  No policy that provides medical, major medical or similar compre-
    21  hensive-type coverage and provides coverage for prescription  drugs  for
    22  medication  for  the treatment of a substance use disorder shall require
    23  prior authorization for an initial  or  renewal  prescription  for  such
    24  drugs for the detoxification or maintenance of a substance use disorder,
    25  including  all  buprenorphine  products,  methadone  [or],  long  acting
    26  injectable naltrexone [for detoxification or maintenance treatment of  a
    27  substance  use  disorder]  and  medication  for opioid overdose reversal
    28  prescribed or dispensed to  an  individual  covered  under  the  policy,
    29  except where otherwise prohibited by law.
    30    §  2.  Subparagraph  (A) of paragraph 7-a of subsection (l) of section
    31  3221 of the insurance law, as added by chapter 748 of the laws of  2019,
    32  is amended to read as follows:
    33    (A)  No policy that provides medical, major medical or similar compre-
    34  hensive-type small group coverage and provides coverage for prescription
    35  drugs for medication for the treatment of a substance use disorder shall
    36  require prior authorization for an initial or renewal  prescription  for
    37  such  drugs  for  the  detoxification  or maintenance of a substance use
    38  disorder, including all buprenorphine products, methadone,  long  acting
    39  injectable  naltrexone,  and  medication  for  opioid  overdose reversal
    40  prescribed or dispensed to  an  individual  covered  under  the  policy,
    41  except  where  otherwise  prohibited  by law. Every policy that provides
    42  medical, major medical or similar comprehensive-type large group  cover-
    43  age shall provide coverage for prescription drugs for medication for the
    44  treatment of a substance use disorder and shall provide immediate cover-
    45  age for all buprenorphine products, methadone [or], long acting injecta-
    46  ble  naltrexone,  and medication for opioid overdose reversal prescribed
    47  or dispensed to an individual covered under  the  policy  without  prior
    48  authorization  for  the  detoxification  or  maintenance  treatment of a
    49  substance use disorder, except where otherwise prohibited by law.
    50    § 3. Subparagraph (A) of paragraph (l-1) of section 4303 of the insur-
    51  ance law, as added by chapter 748 of the laws of  2019,  is  amended  to
    52  read as follows:
    53    (A)  No  contract  that  provides  medical,  major  medical or similar
    54  comprehensive-type individual  or  small  group  coverage  and  provides

        A. 7704                            10
 
     1  coverage  for  prescription  drugs for medication for the treatment of a
     2  substance use disorder shall require prior authorization for an  initial
     3  or renewal prescription for such drugs for the detoxification or mainte-
     4  nance of a substance use disorder, including all buprenorphine products,
     5  methadone,  long acting injectable naltrexone, and medication for opioid
     6  overdose reversal prescribed or dispensed to an individual covered under
     7  the contract, except where otherwise prohibited by law.  Every  contract
     8  that  provides  medical,  major  medical,  or similar comprehensive-type
     9  large group coverage shall provide coverage for prescription  drugs  for
    10  medication  for  the  treatment  of  a  substance use disorder and shall
    11  provide immediate coverage for  all  buprenorphine  products,  methadone
    12  [or], long acting injectable naltrexone, and medication for opioid over-
    13  dose reversal prescribed or dispensed to an individual covered under the
    14  contract  without  prior authorization for the detoxification or mainte-
    15  nance treatment of a substance  use  disorder,  except  where  otherwise
    16  prohibited by law.
    17    § 4. This act shall take effect immediately.
    18    § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
    19  sion,  section  or  part  of  this act shall be adjudged by any court of
    20  competent  jurisdiction to be invalid, such judgment  shall  not affect,
    21  impair,  or  invalidate  the remainder thereof, but shall be confined in
    22  its operation to the clause, sentence, paragraph, subdivision,   section
    23  or part thereof directly involved in the controversy in which such judg-
    24  ment shall have been rendered. It is hereby declared to be the intent of
    25  the  legislature  that  this  act  would  have been enacted even if such
    26  invalid provisions had not been included herein.
    27    § 3. This act shall take effect immediately  provided,  however,  that
    28  the  applicable effective date of Parts A through B of this act shall be
    29  as specifically set forth in the last section of such Parts.
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