Bill Text: NY S07882 | 2013-2014 | General Assembly | Introduced
Bill Title: Relates to insurance coverage for diagnosis and treatment of substance use disorder benefits; creates a workgroup to study and make recommendations on improving access to and the availability of chemical dependency or substance use disorder treatment services.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Introduced - Dead) 2014-06-16 - REFERRED TO RULES [S07882 Detail]
Download: New_York-2013-S07882-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
7882
I N S E N A T E
June 16, 2014
___________
Introduced by Sens. SEWARD, HANNON -- read twice and ordered printed,
and when printed to be committed to the Committee on Rules
AN ACT to amend the insurance law and the public health law, in relation
to requiring health insurance coverage for diagnosis and treatment of
substance use 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:
1 Section 1. Subsection (i) of section 3216 of the insurance law is
2 amended by adding a new paragraph 30 to read as follows:
3 (30) (A) EVERY POLICY THAT PROVIDES MEDICAL, MAJOR-MEDICAL OR SIMILAR
4 COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE COVERAGE FOR DIAGNOSIS AND
5 TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT TO THE FEDERAL
6 PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION
7 EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL AND STATE
8 STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH REQUIRE
9 PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS AND
10 MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND
11 TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER
12 PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS
13 DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
14 TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI-
15 TATION SERVICES.
16 (B) IN THE EVENT OF AN ADVERSE DETERMINATION FOR SUBSTANCE USE DISOR-
17 DER TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE COVER-
18 AGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL THE INSURED HAS EXHAUSTED
19 ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES THE
20 HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED TO NOT MOVE FORWARD
21 WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL ENSURE THAT AN INSURED
22 SHALL NOT INCUR ANY GREATER OUT-OF-POCKET COSTS FOR SUBSTANCE USE DISOR-
23 DER TREATMENT SERVICES RENDERED WHILE THE PROVIDER IS APPEALING AN
24 ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE INSURED WOULD HAVE
25 INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILIZATION REVIEW AGENT.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD15361-11-4
S. 7882 2
1 S 2. Subsection (l) of section 3221 of the insurance law is amended by
2 adding a new paragraph 19 to read as follows:
3 (19) (A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR DELIV-
4 ERY IN THIS STATE WHICH PROVIDES MAJOR MEDICAL OR SIMILAR COMPREHEN-
5 SIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE FOR DIAGNOSIS AND
6 TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT TO THE FEDERAL
7 PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION
8 EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL AND STATE
9 STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH REQUIRE
10 PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS AND
11 MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND
12 TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER
13 PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS
14 DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
15 TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI-
16 TATION SERVICES.
17 (B) IN THE EVENT OF AN ADVERSE DETERMINATION FOR CHEMICAL DEPENDENCE
18 OR SUBSTANCE USE DISORDER TREATMENT SERVICES, THE HEALTH PLAN SHALL
19 CONTINUE TO PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL
20 THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR
21 OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED
22 TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL
23 ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF-POCKET COSTS
24 FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID-
25 ER IS APPEALING AN ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE
26 INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI-
27 ZATION REVIEW AGENT.
28 S 3. Section 4303 of the insurance law is amended by adding a new
29 subsection (oo) to read as follows:
30 (OO) (1) A MEDICAL EXPENSE INDEMNITY CORPORATION, A HOSPITAL SERVICE
31 CORPORATION OR A HEALTH SERVICE CORPORATION WHICH PROVIDES MAJOR MEDICAL
32 OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE
33 FOR DIAGNOSIS AND TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT
34 TO THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND
35 ADDICTION EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL
36 AND STATE STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH
37 REQUIRE PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS
38 AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND
39 TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER
40 PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS
41 DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
42 TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI-
43 TATION SERVICES.
44 (2) IN THE EVENT OF AN ADVERSE DETERMINATION FOR CHEMICAL DEPENDENCE
45 OR SUBSTANCE USE DISORDER TREATMENT SERVICES, THE HEALTH PLAN SHALL
46 CONTINUE TO PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL
47 THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR
48 OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED
49 TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL
50 ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF POCKET COSTS
51 FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID-
52 ER IS APPEALING AN ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE
53 INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI-
54 ZATION REVIEW AGENT.
55 S 4. Section 4902 of the insurance law is amended by adding two new
56 subsections (c) and (d) to read as follows:
S. 7882 3
1 (C) I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF DETERMIN-
2 ING HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISOR-
3 DERS, A UTILIZATION REVIEW AGENT SHALL BE A HEALTH CARE PROVIDER WHO
4 SPECIALIZES IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY
5 OF CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER COURSES OF TREATMENT TO
6 SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO SUCH
7 TREATMENT.
8 II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED
9 AND PEER REVIEWED CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE
10 AGE OF THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR SUCH USE
11 BY THE COMMISSIONER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE
12 SERVICES IN CONSULTATION WITH THE COMMISSIONER OF HEALTH AND THE SUPER-
13 INTENDENT.
14 III. THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSUL-
15 TATION WITH THE COMMISSIONER OF HEALTH AND THE SUPERINTENDENT SHALL
16 APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW
17 CRITERIA, IN ADDITION TO ANY OTHER APPROVED EVIDENCE-BASED AND PEER
18 REVIEWED CLINICAL REVIEW CRITERIA.
19 (D) WHERE AN INSURED'S HEALTHCARE PROVIDER BELIEVES AN IMMEDIATE
20 APPEAL OF AN ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL
21 DEPENDENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL APPEALS
22 SHALL BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B)
23 OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE. WHERE AN
24 INSURED'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN PROVIDING
25 CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT WOULD POSE A
26 SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE INSURED, EXTERNAL APPEALS
27 OF UTILIZATION REVIEW DETERMINATION WILL BE CONDUCTED ON AN EXPEDITED
28 BASIS AS SET FORTH IN PARAGRAPH THREE OF SUBSECTION (B) OF SECTION FOUR
29 THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
30 S 5. Subsection (c) of section 4903 of the insurance law, as amended
31 by chapter 237 of the laws of 2009, is amended to read as follows:
32 (c) A utilization review agent shall make a determination involving
33 continued or extended health care services, additional services for an
34 insured undergoing a course of continued treatment prescribed by a
35 health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
36 SUBSTANCE USE DISORDER, or home health care services following an inpa-
37 tient hospital admission, and shall provide notice of such determination
38 to the insured or the insured's designee, which may be satisfied by
39 notice to the insured's health care provider, by telephone and in writ-
40 ing within one business day of receipt of the necessary information
41 except, with respect to home health care services following an inpatient
42 hospital admission OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
43 SUBSTANCE USE DISORDER, within seventy-two hours of receipt of the
44 necessary information when the day subsequent to the request falls on a
45 weekend or holiday. Notification of continued or extended services shall
46 include the number of extended services approved, the new total of
47 approved services, the date of onset of services and the next review
48 date. Provided that a request for home health care services and all
49 necessary information is submitted to the utilization review agent prior
50 to discharge from an inpatient hospital admission pursuant to this
51 subsection, a utilization review agent shall not deny, on the basis of
52 medical necessity or lack of prior authorization, coverage for home
53 health care services while a determination by the utilization review
54 agent is pending. PROVIDED THAT A REQUEST FOR TREATMENT FOR CHEMICAL
55 DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS
56 SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBSECTION, A
S. 7882 4
1 UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECES-
2 SITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPENDENCE OR
3 SUBSTANCE USE DISORDER TREATMENT WHILE A DETERMINATION BY THE UTILIZA-
4 TION REVIEW AGENT IS PENDING. PROVIDED THAT UPON ADMISSION TO INPATIENT
5 AND RESIDENTIAL TREATMENT FOR CHEMICAL DEPENDENCY OR SUBSTANCE USE
6 DISORDER, THE UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF
7 MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, WHEN NOTICE OF ADMIS-
8 SION FOR PURPOSES OF CARE COORDINATION WAS PROVIDED TO THE UTILIZATION
9 REVIEW AGENT WITHIN TWENTY-FOUR HOURS OF AN ADMISSION; AND A REQUEST FOR
10 TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL
11 NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT
12 PURSUANT TO THIS SUBSECTION.
13 S 6. Subsection (b) of section 4904 of the insurance law, as amended
14 by chapter 237 of the laws of 2009, is amended to read as follows:
15 (b) A utilization review agent shall establish an expedited appeal
16 process for appeal of an adverse determination involving (1) continued
17 or extended health care services, procedures or treatments or additional
18 services for an insured undergoing a course of continued treatment
19 prescribed by a health care provider or home health care services
20 following discharge from an inpatient hospital admission pursuant to
21 subsection (c) of section four thousand nine hundred three of this arti-
22 cle or (2) an adverse determination in which the health care provider
23 believes an immediate appeal is warranted except any retrospective
24 determination. Such process shall include mechanisms which facilitate
25 resolution of the appeal including but not limited to the sharing of
26 information from the insured's health care provider and the utilization
27 review agent by telephonic means or by facsimile. The utilization review
28 agent shall provide reasonable access to its clinical peer reviewer
29 within one business day of receiving notice of the taking of an expe-
30 dited appeal. Expedited appeals shall be determined within two business
31 days of receipt of necessary information to conduct such appeal. Expe-
32 dited appeals which do not result in a resolution satisfactory to the
33 appealing party may be further appealed through the standard appeal
34 process, or through the external appeal process pursuant to section four
35 thousand nine hundred fourteen of this article as applicable. PROVIDED
36 THAT THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER NOTIFIES THE
37 UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME-
38 DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND A REQUEST FOR AN
39 EXPEDITED EXTERNAL APPEAL FOR TREATMENT OF CHEMICAL DEPENDENCE OR
40 SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN
41 TWENTY-FOUR HOURS OF RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION
42 REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK
43 OF PRIOR AUTHORIZATION, COVERAGE FOR SUCH TREATMENT WHILE A DETERMI-
44 NATION BY THE EXTERNAL REVIEW AGENT IS PENDING.
45 S 7. Section 4902 of the public health law is amended by adding two
46 new subdivisions 3 and 4 to read as follows:
47 3. I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF DETERMINING
48 HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDERS,
49 A UTILIZATION REVIEW AGENT SHALL BE A HEALTH CARE PROVIDER WHO SPECIAL-
50 IZES IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY OF
51 CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER COURSES OF TREATMENT TO
52 SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO SUCH
53 TREATMENT.
54 II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED
55 AND PEER REVIEWED CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE
56 AGE OF THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR SUCH USE
S. 7882 5
1 BY THE COMMISSIONER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE
2 SERVICES IN CONSULTATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF
3 FINANCIAL SERVICES.
4 III. THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSUL-
5 TATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL
6 SERVICES SHALL APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED
7 CLINICAL REVIEW CRITERIA, IN ADDITION TO ANY OTHER APPROVED
8 EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA.
9 4. WHERE AN INSURED'S HEALTHCARE PROVIDER BELIEVES AN IMMEDIATE APPEAL
10 OF AN ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL DEPEND-
11 ENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL APPEALS SHALL
12 BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B) OF
13 SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS TITLE. WHERE AN
14 ENROLLEE'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN PROVIDING
15 CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT WOULD POSE A
16 SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE ENROLLEE, EXTERNAL APPEALS
17 OF UTILIZATION REVIEW DETERMINATIONS WILL BE CONDUCTED ON AN EXPEDITED
18 BASIS AS SET FORTH IN PARAGRAPH (C) OF SUBDIVISION TWO OF SECTION FOUR
19 THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
20 S 8. Subdivision 3 of section 4903 of the public health law, as
21 amended by chapter 237 of the laws of 2009, is amended to read as
22 follows:
23 3. A utilization review agent shall make a determination involving
24 continued or extended health care services, additional services for an
25 enrollee undergoing a course of continued treatment prescribed by a
26 health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
27 SUBSTANCE USE DISORDER, or home health care services following an inpa-
28 tient hospital admission, and shall provide notice of such determination
29 to the enrollee or the enrollee's designee, which may be satisfied by
30 notice to the enrollee's health care provider, by telephone and in writ-
31 ing within one business day of receipt of the necessary information
32 except, with respect to home health care services following an inpatient
33 hospital admission, OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
34 SUBSTANCE USE DISORDER, within seventy-two hours of receipt of the
35 necessary information when the day subsequent to the request falls on a
36 weekend or holiday. Notification of continued or extended services shall
37 include the number of extended services approved, the new total of
38 approved services, the date of onset of services and the next review
39 date. Provided that a request for home health care services and all
40 necessary information is submitted to the utilization review agent prior
41 to discharge from an inpatient hospital admission pursuant to this
42 subdivision, a utilization review agent shall not deny, on the basis of
43 medical necessity or lack of prior authorization, coverage for home
44 health care services while a determination by the utilization review
45 agent is pending. PROVIDED THAT A REQUEST FOR TREATMENT FOR CHEMICAL
46 DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS
47 SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBDIVISION,
48 A UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL
49 NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPEND-
50 ENCE OR SUBSTANCE USE DISORDER TREATMENT SERVICES WHILE A DETERMINATION
51 BY THE UTILIZATION REVIEW AGENT IS PENDING. PROVIDED THAT, UPON ADMIS-
52 SION TO INPATIENT AND RESIDENTIAL TREATMENT, THE UTILIZATION REVIEW
53 AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR
54 AUTHORIZATION, WHEN NOTICE OF ADMISSION FOR PURPOSES OF CARE COORDI-
55 NATION WAS PROVIDED TO THE UTILIZATION REVIEW AGENT WITHIN TWENTY-FOUR
56 HOURS OF AN ADMISSION; AND A REQUEST FOR TREATMENT FOR SUBSTANCE USE
S. 7882 6
1 DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION
2 REVIEW AGENT PURSUANT TO THIS SUBDIVISION.
3 S 9. Subdivision 2 of section 4904 of the public health law, as
4 amended by chapter 237 of the laws of 2009, is amended to read as
5 follows:
6 2. A utilization review agent shall establish an expedited appeal
7 process for appeal of an adverse determination involving:
8 (a) continued or extended health care services, procedures or treat-
9 ments or additional services for an enrollee undergoing a course of
10 continued treatment prescribed by a health care provider home health
11 care services following discharge from an inpatient hospital admission
12 pursuant to subdivision three of section forty-nine hundred three of
13 this article; or
14 (b) an adverse determination in which the health care provider
15 believes an immediate appeal is warranted except any retrospective
16 determination. Such process shall include mechanisms which facilitate
17 resolution of the appeal including but not limited to the sharing of
18 information from the enrollee's health care provider and the utilization
19 review agent by telephonic means or by facsimile. The utilization review
20 agent shall provide reasonable access to its clinical peer reviewer
21 within one business day of receiving notice of the taking of an expe-
22 dited appeal. Expedited appeals shall be determined within two business
23 days of receipt of necessary information to conduct such appeal. Expe-
24 dited appeals which do not result in a resolution satisfactory to the
25 appealing party may be further appealed through the standard appeal
26 process, or through the external appeal process pursuant to section
27 forty-nine hundred fourteen of this article as applicable. PROVIDED
28 THAT THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER NOTIFIES THE
29 UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME-
30 DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND A REQUEST FOR AN
31 EXPEDITED EXTERNAL APPEAL FOR TREATMENT OF CHEMICAL DEPENDENCE OR
32 SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN
33 TWENTY-FOUR HOURS OF RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION
34 REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK
35 OF PRIOR AUTHORIZATION, COVERAGE FOR SUCH TREATMENT WHILE A DETERMI-
36 NATION BY THE EXTERNAL REVIEW AGENT IS PENDING.
37 S 10. The superintendent of the department of financial services shall
38 select a random sampling of chemical dependence or substance use disor-
39 der treatment coverage determinations and provide an analysis of whether
40 or not such determinations are in compliance with the criteria estab-
41 lished in this act and report its finding to the governor, the temporary
42 president of the senate, and speaker of the assembly, the chairs of the
43 senate and assembly insurance committees, and the chairs of the senate
44 and assembly health committees no later than December 31, 2015.
45 S 11. 1. Within thirty days of the effective date of this act, the
46 commissioner of the office of alcoholism and substance abuse services,
47 superintendent of the department of financial services, and the commis-
48 sioner of health, shall jointly convene a workgroup to study and make
49 recommendations on improving access to and availability of chemical
50 dependence or substance use disorder treatment services in the state.
51 The workgroup shall be co-chaired by such commissioners and superinten-
52 dent, and shall also include, but not be limited to, representatives of
53 health care providers, insurers, additional professionals, individuals
54 and families who have been affected by addiction. The workgroup shall
55 include, but not be limited to, a review of the following:
S. 7882 7
1 a. Identifying barriers to obtaining necessary chemical dependence or
2 substance use disorder treatment services for across the state;
3 b. Recommendations for increasing access to and availability of chemi-
4 cal dependence or substance use disorder treatment services in the
5 state, including underserved areas of the state;
6 c. Identifying best clinical practices for chemical dependence or
7 substance use disorder treatment services;
8 d. A review of current insurance coverage requirements and recommenda-
9 tions for improving insurance coverage for chemical dependence or
10 substance use disorder and dependency treatment;
11 e. Recommendations for improving state agency communication and
12 collaboration relating to chemical dependence or substance use disorder
13 treatment services in the state;
14 f. Resources for affected individuals and families who are having
15 difficulties obtaining necessary chemical dependence or substance use
16 disorder treatment services; and
17 g. Methods for developing quality standards to measure the performance
18 of chemical dependence or substance use disorder treatment facilities in
19 the state.
20 2. The workgroup shall submit a report of its findings and recommenda-
21 tions to the governor, the temporary president of the senate, the speak-
22 er of the assembly, the chairs of the senate and assembly insurance
23 committees, and the chairs of the senate and assembly health committees
24 no later than December 31, 2015.
25 S 12. This act shall take effect January 1, 2015; provided, however,
26 that sections one through nine of this act shall apply to all policies
27 and contracts issued, delivered, renewed, modified, altered, or amended
28 after such date.
