Bill Text: NY A07522 | 2023-2024 | General Assembly | Introduced
Bill Title: Prohibits the application of fail-first or step therapy protocols to coverage for the diagnosis and treatment of serious mental health conditions; defines serious mental health condition.
Spectrum: Partisan Bill (Democrat 7-0)
Status: (Introduced) 2024-01-03 - referred to insurance [A07522 Detail]
Download: New_York-2023-A07522-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 7522 2023-2024 Regular Sessions IN ASSEMBLY May 25, 2023 ___________ 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 serious mental health conditions The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Item (ii) of subparagraph (A) and subparagraphs (C) and (E) 2 of paragraph 35 of subsection (i) of section 3216 of the insurance law, 3 item (ii) of subparagraph (A) as amended by chapter 62 of the laws of 4 2023 and subparagraphs (C) and (E) as added by section 8 of subpart A of 5 part BB of chapter 57 of the laws of 2019, are amended to read as 6 follows: 7 (ii) where the policy provides coverage for physician services, such 8 policy shall include benefits for outpatient care provided by a psychia- 9 trist or psychologist licensed to practice in this state, a licensed 10 clinical social worker within the lawful scope of his or her practice, 11 who is licensed pursuant to article one hundred fifty-four of the educa- 12 tion law, a mental health counselor, marriage and family therapist, or 13 psychoanalyst licensed pursuant to article one hundred sixty-three of 14 the education law, a nurse practitioner licensed to practice in this 15 state, or a professional corporation or university faculty practice 16 corporation thereof, including outpatient drug coverage. Nothing herein 17 shall be construed to modify or expand the scope of practice of a mental 18 health counselor, marriage and family therapist, or psychoanalyst 19 licensed pursuant to article one hundred sixty-three of the education 20 law. Further, nothing herein shall be construed to create a new mandated 21 health benefit. 22 (C) Coverage under this paragraph shall not apply financial require- 23 ments or treatment limitations to mental health benefits, including 24 outpatient drug coverage, that are more restrictive than the predominant EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD11141-05-3A. 7522 2 1 financial requirements and treatment limitations applied to substantial- 2 ly all medical and surgical benefits covered by the policy. Coverage 3 under this paragraph, including drug coverage, shall not apply any of 4 the following to a drug or drugs prescribed for a serious mental health 5 condition: 6 (i) a fail-first or step therapy protocol, as defined by section four 7 thousand nine hundred of this chapter; or 8 (ii) a prior authorization requirement, as established pursuant to 9 subsection (h) of section four thousand nine hundred three of this chap- 10 ter. 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 therapy 26 protocols; exclusions based on failure to complete a course of treat- 27 ment; 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[.]; and 35 (v) "serious mental health condition" means the following mental 36 health disorders as defined in the most recent edition of the diagnostic 37 and statistical manual of mental disorders: 38 (I) bipolar disorders (hypomanic, manic, depressive, and mixed); 39 (II) depression in childhood and adolescence; 40 (III) major depressive disorders (single episode or recurrent); 41 (IV) obsessive-compulsive disorders; 42 (V) paranoid and other psychotic disorders; 43 (VI) schizoaffective disorders (bipolar or depressive); and 44 (VII) schizophrenia. 45 § 1-a. Items (vi) and (vii) of subparagraph (E) of paragraph 35 of 46 subsection (i) of section 3216 of the insurance law, as added by section 47 2 of subpart A of part II of chapter 57 of the laws of 2023, are amend 48 and a new item (viii) is added to read as follows: 49 (vi) "critical time intervention services" means services rendered by 50 a provider licensed under article thirty-one of the mental hygiene law 51 that provides evidence-based, therapeutic interventions that include 52 intensive outreach, engagement, and care coordination services that are 53 provided to an insured before the insured is discharged from inpatient 54 care in a hospital as defined by subdivision ten of section 1.03 of the 55 mental hygiene law or the emergency department of a hospital licensedA. 7522 3 1 pursuant to article twenty-eight of the public health law and continue 2 after discharge until the insured is stabilized; [and] 3 (vii) "residential facility" means crisis residence facilities and 4 community residences for eating disorder integrated treatment programs 5 licensed pursuant to article thirty-one of the mental hygiene law[.]; 6 and 7 (viii) "serious mental health condition" means the following mental 8 health disorders as defined in the most recent edition of the diagnostic 9 and statistical manual of mental disorders: 10 (I) bipolar disorders (hypomanic, manic, depressive, and mixed); 11 (II) depression in childhood and adolescence; 12 (III) major depressive disorders (single episode or recurrent); 13 (IV) obsessive-compulsive disorders; 14 (V) paranoid and other psychotic disorders; 15 (VI) schizoaffective disorders (bipolar or depressive); and 16 (VII) schizophrenia. 17 § 2. Item (ii) of subparagraph (A) and subparagraphs (C) and (E) of 18 paragraph 5 of subsection (l) of section 3221 of the insurance law, item 19 (ii) of subparagraph (A) as amended by chapter 62 of the laws of 2023 20 and subparagraphs (C) and (E) as added by section 14 of subpart A of 21 part BB of chapter 57 of the laws of 2019, are amended to read as 22 follows: 23 (ii) where the policy provides coverage for physician services, it 24 shall include benefits for outpatient care provided by a psychiatrist or 25 psychologist licensed to practice in this state, or a mental health 26 counselor, marriage and family therapist, or psychoanalyst licensed 27 pursuant to article one hundred sixty-three of the education law, or a 28 licensed clinical social worker within the lawful scope of his or her 29 practice, who is licensed pursuant to article one hundred fifty-four of 30 the education law, a nurse practitioner licensed to practice in this 31 state, or a professional corporation or university faculty practice 32 corporation thereof, including outpatient drug coverage. Nothing herein 33 shall be construed to modify or expand the scope of practice of a mental 34 health counselor, marriage and family therapist, or psychoanalyst 35 licensed pursuant to article one hundred sixty-three of the education 36 law. Further, nothing herein shall be construed to create a new mandated 37 health benefit. 38 (C) Coverage under this paragraph shall not apply financial require- 39 ments or treatment limitations to mental health benefits, including 40 outpatient drug coverage, that are more restrictive than the predominant 41 financial requirements and treatment limitations applied to substantial- 42 ly all medical and surgical benefits covered by the policy. Coverage 43 under this paragraph, including drug coverage, shall not apply any of 44 the following to a drug or drugs prescribed for a serious mental health 45 condition: 46 (i) a fail-first or step therapy protocol, as defined by section four 47 thousand nine hundred of this chapter; or 48 (ii) a prior authorization requirement, as established pursuant to 49 subsection (h) of section four thousand nine hundred three of this chap- 50 ter. 51 (E) For purposes of this paragraph: 52 (i) "financial requirement" means deductible, copayments, coinsurance 53 and out-of-pocket expenses; 54 (ii) "predominant" means that a financial requirement or treatment 55 limitation is the most common or frequent of such type of limit or 56 requirement;A. 7522 4 1 (iii) "treatment limitation" means limits on the frequency of treat- 2 ment, number of visits, days of coverage, or other similar limits on the 3 scope or duration of treatment and includes nonquantitative treatment 4 limitations such as: medical management standards limiting or excluding 5 benefits based on medical necessity, or based on whether the treatment 6 is 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 therapy 10 protocols; exclusions based on failure to complete a course of treat- 11 ment; 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 policy; [and] 14 (iv) "mental health condition" means any mental health disorder as 15 defined in the most recent edition of the diagnostic and statistical 16 manual of mental disorders or the most recent edition of another gener- 17 ally recognized independent standard of current medical practice such as 18 the international classification of diseases[.]; and 19 (v) "serious mental health condition" means the following mental 20 health disorders as defined in the most recent edition of the diagnostic 21 and statistical manual of mental disorders: 22 (I) bipolar disorders (hypomanic, manic, depressive, and mixed); 23 (II) depression in childhood and adolescence; 24 (III) major depressive disorders (single episode or recurrent); 25 (IV) obsessive-compulsive disorders; 26 (V) paranoid and other psychotic disorders; 27 (VI) schizoaffective disorders (bipolar or depressive); and 28 (VII) schizophrenia. 29 § 2-a. Items (vi) and (vii) of subparagraph (E) of paragraph 5 of 30 subsection (l) of section 3221 of the insurance law, as added by section 31 6 of subpart A of part II of chapter 57 of the laws of 2023, are amended 32 and a new item (viii) is added to read as follows: 33 (vi) "critical time intervention services" means services rendered by 34 a provider licensed under article thirty-one of the mental hygiene law 35 that provides evidence-based, therapeutic interventions that include 36 intensive outreach, engagement, and care coordination services that are 37 provided to an insured before the insured is discharged from inpatient 38 care in a hospital as defined by subdivision ten of section 1.03 of the 39 mental hygiene law or the emergency department of a hospital licensed 40 pursuant to article twenty-eight of the public health law and continue 41 after discharge until the insured is stabilized; [and] 42 (vii) "residential facility" means crisis residence facilities and 43 community residences for eating disorder integrated treatment programs 44 licensed pursuant to article thirty-one of the mental hygiene law[.]; 45 and 46 (viii) "serious mental health condition" means the following mental 47 health disorders as defined in the most recent edition of the diagnostic 48 and statistical manual of mental disorders: 49 (I) bipolar disorders (hypomanic, manic, depressive, and mixed); 50 (II) depression in childhood and adolescence; 51 (III) major depressive disorders (single episode or recurrent); 52 (IV) obsessive-compulsive disorders; 53 (V) paranoid and other psychotic disorders; 54 (VI) schizoaffective disorders (bipolar or depressive); and 55 (VII) schizophrenia.A. 7522 5 1 § 3. Paragraphs 2, 4, and 6 of subsection (g) of section 4303 of the 2 insurance law, paragraph 2 as amended by chapter 62 of the laws of 2023, 3 and paragraphs 4 and 6 as added by section 23 of subpart A of part BB of 4 chapter 57 of the laws of 2019, are amended to read as follows: 5 (2) where the contract provides coverage for physician services such 6 contract shall provide benefits for outpatient care provided by a 7 psychiatrist or psychologist licensed to practice in this state, or a 8 mental health counselor, marriage and family therapist, or psychoanalyst 9 licensed pursuant to article one hundred sixty-three of the education 10 law, or a licensed clinical social worker within the lawful scope of his 11 or her practice, who is licensed pursuant to article one hundred fifty- 12 four of the education law, a nurse practitioner licensed to practice in 13 this state, or professional corporation or university faculty practice 14 corporation thereof, including outpatient drug coverage. Nothing herein 15 shall be construed to modify or expand the scope of practice of a mental 16 health counselor, marriage and family therapist, or psychoanalyst 17 licensed pursuant to article one hundred sixty-three of the education 18 law. Further, nothing herein shall be construed to create a new mandated 19 health benefit. 20 (4) Coverage under this subsection shall not apply financial require- 21 ments or treatment limitations to mental health benefits, including 22 outpatient drug coverage, that are more restrictive than the predominant 23 financial requirements and treatment limitations applied to substantial- 24 ly all medical and surgical benefits covered by the contract. Coverage 25 under this paragraph, including drug coverage, shall not apply any of 26 the following to a drug or drugs prescribed for a serious mental health 27 condition: 28 (i) a fail-first or step therapy protocol, as defined by section four 29 thousand nine hundred of this chapter; or 30 (ii) a prior authorization requirement, as established pursuant to 31 subsection (h) of section four thousand nine hundred three of this chap- 32 ter. 33 (6) For purposes of this subsection: 34 (A) "financial requirement" means deductible, copayments, coinsurance 35 and out-of-pocket expenses; 36 (B) "predominant" means that a financial requirement or treatment 37 limitation is the most common or frequent of such type of limit or 38 requirement; 39 (C) "treatment limitation" means limits on the frequency of treatment, 40 number of visits, days of coverage, or other similar limits on the scope 41 or duration of treatment and includes nonquantitative treatment limita- 42 tions such as: medical management standards limiting or excluding bene- 43 fits based on medical necessity, or based on whether the treatment is 44 experimental or investigational; formulary design for prescription 45 drugs; network tier design; standards for provider admission to partic- 46 ipate in a network, including reimbursement rates; methods for determin- 47 ing usual, customary, and reasonable charges; fail-first or step therapy 48 protocols; exclusions based on failure to complete a course of treat- 49 ment; and restrictions based on geographic location, facility type, 50 provider specialty, and other criteria that limit the scope or duration 51 of benefits for services provided under the contract; [and] 52 (D) "mental health condition" means any mental health disorder as 53 defined in the most recent edition of the diagnostic and statistical 54 manual of mental disorders or the most recent edition of another gener- 55 ally recognized independent standard of current medical practice such as 56 the international classification of diseases[.]; andA. 7522 6 1 (E) "serious mental health condition" means the following mental 2 health disorders as defined in the most recent edition of the diagnostic 3 and statistical manual of mental disorders: 4 (i) bipolar disorders (hypomanic, manic, depressive, and mixed); 5 (ii) depression in childhood and adolescence; 6 (iii) major depressive disorders (single episode or recurrent); 7 (iv) obsessive-compulsive disorders; 8 (v) paranoid and other psychotic disorders; 9 (vi) schizoaffective disorders (bipolar or depressive); and 10 (vii) schizophrenia. 11 § 3-a. Subparagraphs (F) and (G) of paragraph 6 of subsection (g) of 12 section 4303 of the insurance law, as added by section 10 of subpart A 13 of part II of chapter 57 of the laws of 2023, are amended and a new 14 subparagraph (H) is added to read as follows: 15 (F) "critical time intervention services" means services rendered by a 16 provider licensed under article thirty-one of the mental hygiene law 17 that provides evidence-based, therapeutic interventions that include 18 intensive outreach, engagement, and care coordination services that are 19 provided to an insured before the insured is discharged from inpatient 20 care in a hospital as defined by subdivision ten of section 1.03 of the 21 mental hygiene law or the emergency department of a hospital licensed 22 pursuant to article twenty-eight of the public health law and continue 23 after discharge until the insured is stabilized; [and] 24 (G) "residential facility" means crisis residence facilities and 25 community residences for eating disorder integrated treatment programs 26 licensed pursuant to article thirty-one of the mental hygiene law[.]; 27 and 28 (H) "serious mental health condition" means the following mental 29 health disorders as defined in the most recent edition of the diagnostic 30 and statistical manual of mental disorders: 31 (i) bipolar disorders (hypomanic, manic, depressive, and mixed); 32 (ii) depression in childhood and adolescence; 33 (iii) major depressive disorders (single episode or recurrent); 34 (iv) obsessive-compulsive disorders; 35 (v) paranoid and other psychotic disorders; 36 (vi) schizoaffective disorders (bipolar or depressive); and 37 (vii) schizophrenia. 38 § 4. This act shall take effect on the first of January next succeed- 39 ing the date on which it shall have become a law and shall apply to all 40 policies and contracts issued, renewed, modified, altered or amended on 41 or after such date; provided however, that if subpart A of part II of 42 chapter 57 of the laws of 2023 shall not have taken effect on or before 43 such date then sections one-a, two-a and three-a of this act shall take 44 effect on the same date and in the same manner as such subpart of such 45 part of such chapter of the laws of 2023 takes effect.
