Bill Text: NY A11145 | 2019-2020 | General Assembly | Introduced

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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 1-0)

Status: (Introduced - Dead) 2020-11-06 - referred to insurance [A11145 Detail]

Download: New_York-2019-A11145-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          11145

                   IN ASSEMBLY

                                    November 6, 2020
                                       ___________

        Introduced  by COMMITTEE ON RULES -- (at request of M. of A. Gunther) --
          read once and referred to the Committee 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.
    25    (C)  Coverage  under this paragraph shall not apply financial require-
    26  ments or treatment limitations to mental health benefits, including drug
    27  coverage, that are  more  restrictive  than  the  predominant  financial

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD17540-01-0
        A. 11145                            2

     1  requirements  and  treatment  limitations  applied  to substantially all
     2  medical and surgical benefits covered by the policy. Coverage under this
     3  paragraph, including drug coverage, shall not apply  any  fail-first  or
     4  step  therapy protocol, as defined by section four thousand nine hundred
     5  of this chapter.
     6    (E) For purposes of this paragraph:
     7    (i) "financial requirement" means deductible, copayments,  coinsurance
     8  and out-of-pocket expenses;
     9    (ii)  "predominant"  means  that  a financial requirement or treatment
    10  limitation is the most common or frequent  of  such  type  of  limit  or
    11  requirement;
    12    (iii)  "treatment  limitation" means limits on the frequency of treat-
    13  ment, number of visits, days of coverage, or other similar limits on the
    14  scope or duration of treatment and  includes  nonquantitative  treatment
    15  limitations  such as: medical management standards limiting or excluding
    16  benefits based on medical necessity, or based on whether  the  treatment
    17  is  experimental  or  investigational; formulary design for prescription
    18  drugs; network tier design; standards for provider admission to  partic-
    19  ipate in a network, including reimbursement rates; methods for determin-
    20  ing usual, customary, and reasonable charges; [fail-first or step thera-
    21  py  protocols;]  exclusions  based  on  failure  to complete a course of
    22  treatment; and restrictions based on geographic location, facility type,
    23  provider specialty, and other criteria that limit the scope or  duration
    24  of benefits for services provided under the policy; and
    25    (iv)  "mental  health  condition"  means any mental health disorder as
    26  defined in the most recent edition of  the  diagnostic  and  statistical
    27  manual  of mental disorders or the most recent edition of another gener-
    28  ally recognized independent standard of current medical practice such as
    29  the international classification of diseases.
    30    § 2. Subparagraphs (A), (C) and (E) of paragraph 5 of  subsection  (l)
    31  of  section  3221  of  the insurance law, subparagraph (A) as amended by
    32  section 13 of subpart A of part BB of chapter 57 of the laws of 2019 and
    33  subparagraphs (C) and (E) as added by section 14 of subpart A of part BB
    34  of chapter 57 of the laws of 2019, are amended to read as follows:
    35    (A) Every insurer delivering a group or school blanket policy or issu-
    36  ing a group or school blanket policy for delivery, in this state,  which
    37  provides  coverage for inpatient hospital care or coverage for physician
    38  services shall provide coverage  for  the  diagnosis  and  treatment  of
    39  mental health conditions and:
    40    (i)  where  the  policy provides coverage for inpatient hospital care,
    41  benefits for inpatient care in a hospital as defined by subdivision  ten
    42  of  section  1.03  of the mental hygiene law and benefits for outpatient
    43  care provided in a facility  issued  an  operating  certificate  by  the
    44  commissioner  of  mental  health  pursuant  to the provisions of article
    45  thirty-one of the mental hygiene law, or in a facility operated  by  the
    46  office  of mental health or, for care provided in other states, to simi-
    47  larly licensed or certified hospitals or facilities; and
    48    (ii) where the policy provides coverage  for  physician  services,  it
    49  shall include benefits for outpatient care provided by a psychiatrist or
    50  psychologist  licensed  to  practice  in this state, a licensed clinical
    51  social worker who meets the requirements of subparagraph  (D)  of  para-
    52  graph four of this subsection, a nurse practitioner licensed to practice
    53  in this state, or a professional corporation or university faculty prac-
    54  tice corporation thereof, including outpatient drug coverage.
    55    (C)  Coverage  under this paragraph shall not apply financial require-
    56  ments or treatment limitations to mental health benefits, including drug
        A. 11145                            3

     1  coverage, that are  more  restrictive  than  the  predominant  financial
     2  requirements  and  treatment  limitations  applied  to substantially all
     3  medical and surgical benefits covered by the policy. Coverage under this
     4  paragraph,  including  drug  coverage, shall not apply any fail-first or
     5  step therapy protocol, as defined by section four thousand nine  hundred
     6  of this chapter.
     7    (E) For purposes of this paragraph:
     8    (i)  "financial requirement" means deductible, copayments, coinsurance
     9  and out-of-pocket expenses;
    10    (ii) "predominant" means that a  financial  requirement  or  treatment
    11  limitation  is  the  most  common  or  frequent of such type of limit or
    12  requirement;
    13    (iii) "treatment limitation" means limits on the frequency  of  treat-
    14  ment, number of visits, days of coverage, or other similar limits on the
    15  scope  or  duration  of treatment and includes nonquantitative treatment
    16  limitations such as: medical management standards limiting or  excluding
    17  benefits  based  on medical necessity, or based on whether the treatment
    18  is experimental or investigational; formulary  design  for  prescription
    19  drugs;  network tier design; standards for provider admission to partic-
    20  ipate in a network, including reimbursement rates; methods for determin-
    21  ing usual, customary, and reasonable charges; [fail-first or step thera-
    22  py protocols;] exclusions based on  failure  to  complete  a  course  of
    23  treatment; and restrictions based on geographic location, facility type,
    24  provider  specialty, and other criteria that limit the scope or duration
    25  of benefits for services provided under the policy; and
    26    (iv) "mental health condition" means any  mental  health  disorder  as
    27  defined  in  the  most  recent edition of the diagnostic and statistical
    28  manual of mental disorders or the most recent edition of another  gener-
    29  ally recognized independent standard of current medical practice such as
    30  the international classification of diseases.
    31    §  3.  Paragraphs  2  and  4,  and  subparagraph (C) of paragraph 6 of
    32  subsection (g) of section 4303 of the  insurance  law,  paragraph  2  as
    33  added by section 22 of subpart A of part BB of chapter 57 of the laws of
    34  2019,  and  paragraph  4 and subparagraph (C) of paragraph 6 as added by
    35  section 23 of subpart A of part BB of chapter 57 of the  laws  of  2019,
    36  are amended the read as follows:
    37    (2)  where the contract provides coverage for physician services bene-
    38  fits for outpatient care provided  by  a  psychiatrist  or  psychologist
    39  licensed  to  practice  in this state, a licensed clinical social worker
    40  who meets the requirements of subsection (n) of this  section,  a  nurse
    41  practitioner  licensed to practice on this state, or professional corpo-
    42  ration or university faculty  practice  corporation  thereof,  including
    43  outpatient drug coverage.
    44    (4)  Coverage under this subsection shall not apply financial require-
    45  ments or treatment limitations to mental health benefits, including drug
    46  coverage, that are  more  restrictive  than  the  predominant  financial
    47  requirements  and  treatment  limitations  applied  to substantially all
    48  medical and surgical benefits covered by the contract.   Coverage  under
    49  this  paragraph, including drug coverage, shall not apply any fail-first
    50  or step therapy protocol, as  defined  by  section  four  thousand  nine
    51  hundred of this chapter.
    52    (C) "treatment limitation" means limits on the frequency of treatment,
    53  number of visits, days of coverage, or other similar limits on the scope
    54  or  duration of treatment and includes nonquantitative treatment limita-
    55  tions such as: medical management standards limiting or excluding  bene-
    56  fits  based  on  medical necessity, or based on whether the treatment is
        A. 11145                            4

     1  experimental  or  investigational;  formulary  design  for  prescription
     2  drugs;  network tier design; standards for provider admission to partic-
     3  ipate in a network, including reimbursement rates; methods for determin-
     4  ing usual, customary, and reasonable charges; [fail-first or step thera-
     5  py  protocols;]  exclusions  based  on  failure  to complete a course of
     6  treatment; and restrictions based on geographic location, facility type,
     7  provider specialty, and other criteria that limit the scope or  duration
     8  of benefits for services provided under the contract; and
     9    §  4.  This  act  shall take effect immediately and shall apply to all
    10  policies and contracts issued, renewed, modified, altered or amended  on
    11  or after such date.