Bill Text: NY A03104 | 2023-2024 | General Assembly | Introduced
Bill Title: Includes clinically necessary treatment for certain inpatient coverage, which shall mean an individual's medical needs and any social determinants of health that will promote such individual's stability following discharge from treatment.
Spectrum: Partisan Bill (Democrat 4-0)
Status: (Introduced) 2024-01-03 - referred to insurance [A03104 Detail]
Download: New_York-2023-A03104-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 3104 2023-2024 Regular Sessions IN ASSEMBLY February 2, 2023 ___________ Introduced by M. of A. McDONALD -- read once and referred to the Commit- tee on Insurance AN ACT to amend the insurance law, in relation to including clinically necessary treatment for certain inpatient coverage The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Paragraph 30 of subsection (i) of section 3216 of the 2 insurance law, as amended by section 5 of subpart A of part BB of chap- 3 ter 57 of the laws of 2019, is amended to read as follows: 4 (30)(A) Every policy that provides hospital, major medical or similar 5 comprehensive coverage shall provide inpatient coverage for the diagno- 6 sis and treatment of substance use disorder, including detoxification 7 and rehabilitation services. Such inpatient coverage [shall] may include 8 [unlimited medically] clinically necessary treatment for substance use 9 disorder treatment services provided in residential settings at the 10 discretion of the service provider. Further, such inpatient coverage 11 shall not apply financial requirements or treatment limitations, includ- 12 ing utilization review requirements, to inpatient substance use disorder 13 benefits that are more restrictive than the predominant financial 14 requirements and treatment limitations applied to substantially all 15 medical and surgical benefits covered by the policy. 16 (B) Coverage provided under this paragraph may be limited to facili- 17 ties in New York state that are licensed, certified or otherwise author- 18 ized by the office of [alcoholism and substance abuse] addiction 19 services and supports and, in other states, to those which are accred- 20 ited by the joint commission as alcoholism, substance abuse, or chemical 21 dependence treatment programs and are similarly licensed, certified or 22 otherwise authorized in the state in which the facility is located. 23 (C) Coverage provided under this paragraph may be subject to annual 24 deductibles and co-insurance as deemed appropriate by the superintendent EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD04901-01-3A. 3104 2 1 and that are consistent with those imposed on other benefits within a 2 given policy. 3 (D) This subparagraph shall apply to facilities in this state that are 4 licensed, certified or otherwise authorized by the office of [alcoholism5and substance abuse] addiction services and supports that are partic- 6 ipating in the insurer's provider network. Coverage provided under this 7 paragraph shall not be subject to preauthorization. Coverage provided 8 under this paragraph shall also not be subject to concurrent utilization 9 review during the first twenty-eight days of the inpatient admission 10 provided that the facility notifies the insurer of both the admission 11 and the initial treatment plan within two business days of the admis- 12 sion. The facility shall perform daily clinical review of the patient, 13 including periodic consultation with the insurer at or just prior to the 14 fourteenth day of treatment to ensure that the facility is using the 15 evidence-based and peer reviewed clinical review tool utilized by the 16 insurer which is designated by the office of [alcoholism and substance17abuse] addiction services and supports and appropriate to the age of the 18 patient, to ensure that the inpatient treatment is [medically] clin- 19 ically necessary for the patient. Prior to discharge, the facility shall 20 provide the patient and the insurer with a written discharge plan which 21 shall describe arrangements for additional services needed following 22 discharge from the inpatient facility as determined using the evidence- 23 based and peer-reviewed clinical review tool utilized by the insurer 24 which is designated by the office of [alcoholism and substance abuse] 25 addiction services and supports. Prior to discharge, the facility shall 26 indicate to the insurer whether services included in the discharge plan 27 are secured or determined to be reasonably available. Any utilization 28 review of treatment provided under this subparagraph may include a 29 review of all services provided during such inpatient treatment, includ- 30 ing all services provided during the first twenty-eight days of such 31 inpatient treatment. Provided, however, [the] such utilization review 32 shall only be imposed to the extent the insurer's requirements are 33 permitted under the federal Paul Wellstone and Pete Domenici Mental 34 Health Parity and Addiction Equity Act of 2008 and applicable regu- 35 lations (29 U.S.C. § 1185a; 42 U.S.C. § 300gg-26; 45 C.F.R. Parts 146, 36 147). The insurer [shall] may only deny coverage for any portion of the 37 initial twenty-eight day inpatient treatment on the basis that such 38 treatment was not [medically] clinically necessary if such inpatient 39 treatment was [contrary to] not indicated by the evidence-based and peer 40 reviewed clinical review tool utilized by the insurer which is desig- 41 nated by the office of [alcoholism and substance abuse] addiction 42 services and supports. Any denial must specifically identify: (i) how 43 such treatment was not indicated by the office of addiction services and 44 supports designated clinical review tool; and (ii) how the policy 45 applied the office of addiction services and supports designated tool to 46 the outpatient substance use disorder care in a manner comparable to and 47 no more stringent than the policy's application of its clinical review 48 tool for outpatient medical and surgical benefits covered by the policy. 49 Any concurrent or retrospective review imposed by the plan, both as 50 written and as applied, must be consistent with the federal Paul Well- 51 stone and Pete Domenici Mental Health Parity and Addiction Equity Act of 52 2008 and applicable regulations (29 U.S.C. § 1185a; 42 U.S.C. § 300gg- 53 26; 45 C.F.R. Parts 146, 147). An insured shall not have any financial 54 obligation to the facility for any treatment under this subparagraph 55 other than any copayment, coinsurance, or deductible otherwise required 56 under the policy.A. 3104 3 1 (E) An insurer shall make available to any insured, prospective 2 insured, or in-network provider, upon request, the criteria for 3 [medical] clinical necessity determinations under the policy with 4 respect to inpatient substance use disorder benefits. 5 (F) For purposes of this paragraph: 6 (i) "financial requirement" means deductible, copayments, coinsurance 7 and out-of-pocket expenses; 8 (ii) "predominant" means that a financial requirement or treatment 9 limitation is the most common or frequent of such type of limit or 10 requirement; 11 (iii) "treatment limitation" means limits on the frequency of treat- 12 ment, number of visits, days of coverage, or other similar limits on the 13 scope or duration of treatment and includes nonquantitative treatment 14 limitations such as: medical management standards limiting or excluding 15 benefits based on [medical] clinical necessity, or based on whether the 16 treatment is experimental or investigational; formulary design for 17 prescription drugs; network tier design; standards for provider admis- 18 sion to participate in a network, including reimbursement rates; methods 19 for determining usual, customary, and reasonable charges; fail-first or 20 step therapy protocols; exclusions based on failure to complete a course 21 of treatment; and restrictions based on geographic location, facility 22 type, provider specialty, and other criteria that limit the scope or 23 duration of benefits for services provided under the policy; [and] 24 (iv) "substance use disorder" shall have the meaning set forth in the 25 most recent edition of the diagnostic and statistical manual of mental 26 disorders or the most recent edition of another generally recognized 27 independent standard of current medical practice, such as the interna- 28 tional classification of diseases[.]; and 29 (v) "clinical necessity" means both an individual's medical needs and 30 any social determinants of health that will promote such individual's 31 stability following discharge from treatment. 32 (G) An insurer shall provide coverage under this paragraph, at a mini- 33 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 34 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 35 § 2. This act shall take effect immediately.
