Bill Text: NY A03276 | 2021-2022 | General Assembly | Introduced
Bill Title: Prohibits the application of fail-first or step therapy protocols to coverage for the diagnosis and treatment of mental health conditions.
Spectrum: Partisan Bill (Democrat 8-0)
Status: (Vetoed) 2022-12-23 - tabled [A03276 Detail]
Download: New_York-2021-A03276-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 3276 2021-2022 Regular Sessions IN ASSEMBLY January 22, 2021 ___________ Introduced by M. of A. GUNTHER -- read once and referred to the Commit- tee on Insurance AN ACT to amend the insurance law, in relation to prohibiting the appli- cation of fail-first or step therapy protocols to coverage for the diagnosis and treatment of mental health conditions The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subparagraphs (A), (C) and (E) of paragraph 35 of 2 subsection (i) of section 3216 of the insurance law, as added by section 3 8 of subpart A of part BB of chapter 57 of the laws of 2019, are amended 4 to read as follows: 5 (A) Every policy delivered or issued for delivery in this state that 6 provides coverage for inpatient hospital care or coverage for physician 7 services shall provide coverage for the diagnosis and treatment of 8 mental health conditions as follows: 9 (i) where the policy provides coverage for inpatient hospital care, 10 benefits for inpatient care in a hospital as defined by subdivision ten 11 of section 1.03 of the mental hygiene law and benefits for outpatient 12 care provided in a facility issued an operating certificate by the 13 commissioner of mental health pursuant to the provisions of article 14 thirty-one of the mental hygiene law, or in a facility operated by the 15 office of mental health, or, for care provided in other states, to simi- 16 larly licensed or certified hospitals or facilities; and 17 (ii) where the policy provides coverage for physician services, bene- 18 fits for outpatient care provided by a psychiatrist or psychologist 19 licensed to practice in this state, a licensed clinical social worker 20 who meets the requirements of subparagraph (D) of paragraph four of 21 subsection (1) of section three thousand two hundred twenty-one of this 22 article, a nurse practitioner licensed to practice in this state, or a 23 professional corporation or university faculty practice corporation 24 thereof, including outpatient drug coverage. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD02946-01-1A. 3276 2 1 (C) Coverage under this paragraph shall not apply financial require- 2 ments or treatment limitations to mental health benefits, including drug 3 coverage, that are more restrictive than the predominant financial 4 requirements and treatment limitations applied to substantially all 5 medical and surgical benefits covered by the policy. Coverage under this 6 paragraph, including drug coverage, shall not apply any fail-first or 7 step therapy protocol, as defined by section four thousand nine hundred 8 of this chapter. 9 (E) For purposes of this paragraph: 10 (i) "financial requirement" means deductible, copayments, coinsurance 11 and out-of-pocket expenses; 12 (ii) "predominant" means that a financial requirement or treatment 13 limitation is the most common or frequent of such type of limit or 14 requirement; 15 (iii) "treatment limitation" means limits on the frequency of treat- 16 ment, number of visits, days of coverage, or other similar limits on the 17 scope or duration of treatment and includes nonquantitative treatment 18 limitations such as: medical management standards limiting or excluding 19 benefits based on medical necessity, or based on whether the treatment 20 is experimental or investigational; formulary design for prescription 21 drugs; network tier design; standards for provider admission to partic- 22 ipate in a network, including reimbursement rates; methods for determin- 23 ing usual, customary, and reasonable charges; [fail-first or step thera-24py protocols;] exclusions based on failure to complete a course of 25 treatment; and restrictions based on geographic location, facility type, 26 provider specialty, and other criteria that limit the scope or duration 27 of benefits for services provided under the policy; and 28 (iv) "mental health condition" means any mental health disorder as 29 defined in the most recent edition of the diagnostic and statistical 30 manual of mental disorders or the most recent edition of another gener- 31 ally recognized independent standard of current medical practice such as 32 the international classification of diseases. 33 § 2. Subparagraphs (A), (C) and (E) of paragraph 5 of subsection (l) 34 of section 3221 of the insurance law, subparagraph (A) as amended by 35 section 13 of subpart A of part BB of chapter 57 of the laws of 2019 and 36 subparagraphs (C) and (E) as added by section 14 of subpart A of part BB 37 of chapter 57 of the laws of 2019, are amended to read as follows: 38 (A) Every insurer delivering a group or school blanket policy or issu- 39 ing a group or school blanket policy for delivery, in this state, which 40 provides coverage for inpatient hospital care or coverage for physician 41 services shall provide coverage for the diagnosis and treatment of 42 mental health conditions and: 43 (i) where the policy provides coverage for inpatient hospital care, 44 benefits for inpatient care in a hospital as defined by subdivision ten 45 of section 1.03 of the mental hygiene law and benefits for outpatient 46 care provided in a facility issued an operating certificate by the 47 commissioner of mental health pursuant to the provisions of article 48 thirty-one of the mental hygiene law, or in a facility operated by the 49 office of mental health or, for care provided in other states, to simi- 50 larly licensed or certified hospitals or facilities; and 51 (ii) where the policy provides coverage for physician services, it 52 shall include benefits for outpatient care provided by a psychiatrist or 53 psychologist licensed to practice in this state, a licensed clinical 54 social worker who meets the requirements of subparagraph (D) of para- 55 graph four of this subsection, a nurse practitioner licensed to practiceA. 3276 3 1 in this state, or a professional corporation or university faculty prac- 2 tice corporation thereof, including outpatient drug coverage. 3 (C) Coverage under this paragraph shall not apply financial require- 4 ments or treatment limitations to mental health benefits, including drug 5 coverage, that are more restrictive than the predominant financial 6 requirements and treatment limitations applied to substantially all 7 medical and surgical benefits covered by the policy. Coverage under this 8 paragraph, including drug coverage, shall not apply any fail-first or 9 step therapy protocol, as defined by section four thousand nine hundred 10 of this chapter. 11 (E) For purposes of this paragraph: 12 (i) "financial requirement" means deductible, copayments, coinsurance 13 and out-of-pocket expenses; 14 (ii) "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 (iii) "treatment limitation" means limits on the frequency of treat- 18 ment, number of visits, days of coverage, or other similar limits on the 19 scope or duration of treatment and includes nonquantitative treatment 20 limitations such as: medical management standards limiting or excluding 21 benefits based on medical necessity, or based on whether the treatment 22 is experimental or investigational; formulary design for prescription 23 drugs; network tier design; standards for provider admission to partic- 24 ipate in a network, including reimbursement rates; methods for determin- 25 ing usual, customary, and reasonable charges; [fail-first or step thera-26py protocols;] exclusions based on failure to complete a course of 27 treatment; and restrictions based on geographic location, facility type, 28 provider specialty, and other criteria that limit the scope or duration 29 of benefits for services provided under the policy; and 30 (iv) "mental health condition" means any mental health disorder as 31 defined in the most recent edition of the diagnostic and statistical 32 manual of mental disorders or the most recent edition of another gener- 33 ally recognized independent standard of current medical practice such as 34 the international classification of diseases. 35 § 3. Paragraphs 2 and 4, and subparagraph (C) of paragraph 6 of 36 subsection (g) of section 4303 of the insurance law, paragraph 2 as 37 added by section 22 of subpart A of part BB of chapter 57 of the laws of 38 2019, and paragraph 4 and subparagraph (C) of paragraph 6 as added by 39 section 23 of subpart A of part BB of chapter 57 of the laws of 2019, 40 are amended the read as follows: 41 (2) where the contract provides coverage for physician services bene- 42 fits for outpatient care provided by a psychiatrist or psychologist 43 licensed to practice in this state, a licensed clinical social worker 44 who meets the requirements of subsection (n) of this section, a nurse 45 practitioner licensed to practice on this state, or professional corpo- 46 ration or university faculty practice corporation thereof, including 47 outpatient drug coverage. 48 (4) Coverage under this subsection shall not apply financial require- 49 ments or treatment limitations to mental health benefits, including drug 50 coverage, that are more restrictive than the predominant financial 51 requirements and treatment limitations applied to substantially all 52 medical and surgical benefits covered by the contract. Coverage under 53 this paragraph, including drug coverage, shall not apply any fail-first 54 or step therapy protocol, as defined by section four thousand nine 55 hundred of this chapter.A. 3276 4 1 (C) "treatment limitation" means limits on the frequency of treatment, 2 number of visits, days of coverage, or other similar limits on the scope 3 or duration of treatment and includes nonquantitative treatment limita- 4 tions such as: medical management standards limiting or excluding bene- 5 fits based on medical necessity, or based on whether the treatment is 6 experimental or investigational; formulary design for prescription 7 drugs; network tier design; standards for provider admission to partic- 8 ipate in a network, including reimbursement rates; methods for determin- 9 ing usual, customary, and reasonable charges; [fail-first or step thera-10py protocols;] exclusions based on failure to complete a course of 11 treatment; and restrictions based on geographic location, facility type, 12 provider specialty, and other criteria that limit the scope or duration 13 of benefits for services provided under the contract; and 14 § 4. This act shall take effect immediately and shall apply to all 15 policies and contracts issued, renewed, modified, altered or amended on 16 or after such date.