STATE OF NEW YORK
________________________________________________________________________
7288--A
2023-2024 Regular Sessions
IN SENATE
May 19, 2023
___________
Introduced by Sens. FERNANDEZ, KENNEDY, RYAN -- read twice and ordered
printed, and when printed to be committed to the Committee on Insur-
ance -- recommitted to the Committee on Insurance in accordance with
Senate Rule 6, sec. 8 -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee
AN ACT to amend the insurance law, in relation to certain cost sharing
fees for outpatient treatment at a substance use treatment program
The People of the State of New York, represented in Senate and Assem-
bly, do enact as follows:
1 Section 1. Subparagraph (E) of paragraph 31 of subsection (i) of
2 section 3216 of the insurance law, as amended by section 6 of subpart A
3 of part BB of chapter 57 of the laws of 2019, is amended and a new
4 subparagraph (J) is added to read as follows:
5 (E) This subparagraph shall apply to facilities in this state that are
6 licensed, certified or otherwise authorized by the office of [alcoholism
7 and substance abuse] addiction services and supports for the provision
8 of outpatient, intensive outpatient, outpatient rehabilitation and
9 opioid treatment that are participating in the insurer's provider
10 network. Coverage provided under this paragraph shall not be subject to
11 preauthorization. Coverage provided under this paragraph shall not be
12 subject to concurrent review for the first four weeks of continuous
13 treatment, not to exceed twenty-eight visits, provided the facility
14 notifies the insurer of both the start of treatment and the initial
15 treatment plan within two business days. The facility shall perform
16 clinical assessment of the patient at each visit, including periodic
17 consultation with the insurer at or just prior to the fourteenth day of
18 treatment to ensure that the facility is using the evidence-based and
19 peer reviewed clinical review tool utilized by the insurer which is
20 designated by the office of [alcoholism and substance abuse] addiction
21 services and supports and appropriate to the age of the patient, to
22 ensure that the outpatient treatment is medically necessary for the
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD11569-03-4
S. 7288--A 2
1 patient. Any utilization review of the treatment provided under this
2 subparagraph may include a review of all services provided during such
3 outpatient treatment, including all services provided during the first
4 four weeks of continuous treatment, not to exceed twenty-eight visits,
5 of such outpatient treatment. Provided, however, the insurer shall only
6 deny coverage for any portion of the initial four weeks of continuous
7 treatment, not to exceed twenty-eight visits, for outpatient treatment
8 on the basis that such treatment was not medically necessary if such
9 outpatient treatment was contrary to the evidence-based and peer
10 reviewed clinical review tool utilized by the insurer which is desig-
11 nated by the office of [alcoholism and substance abuse] addiction
12 services and supports. An insured shall only have financial responsibil-
13 ities as set out in subparagraph (J) of this paragraph and shall not
14 have any financial obligation to the facility for any treatment under
15 this subparagraph other than any [copayment,] coinsurance[, or deduct-
16 ible] otherwise required under the policy.
17 (J) For a substance use disorder outpatient treatment episode of care
18 by a provider licensed, certified or otherwise authorized by the office
19 of addiction services and supports, an insured shall only be responsible
20 for a cost sharing fee not to exceed five hundred dollars. An insurer
21 providing coverage under this paragraph shall be responsible for all
22 other financial obligations to the facility. An episode of care is
23 defined to include up to sixty visits with the same treatment provider.
24 § 2. Subparagraphs (C-1) and (E) of paragraph 7 of subsection (l) of
25 section 3221 of the insurance law, subparagraph (C-1) as added by
26 section 16 and subparagraph (E) as amended by section 17 of subpart A of
27 part BB of chapter 57 of the laws of 2019, are amended and a new subpar-
28 agraph (J) is added to read as follows:
29 (C-1) A large group policy that provides coverage under this paragraph
30 shall not impose [copayments or] coinsurance for outpatient substance
31 use disorder services that exceeds the [copayment or] coinsurance
32 imposed for a primary care office visit. [Provided that no greater than
33 one such copayment may be imposed for all services provided in a single
34 day by a facility licensed, certified or otherwise authorized by the
35 office of alcoholism and substance abuse services to provide outpatient
36 substance use disorder services] A large group policy that provides
37 coverage under this paragraph shall not impose copayments for outpatient
38 substance use disorder services.
39 (E) This subparagraph shall apply to facilities in this state that are
40 licensed, certified or otherwise authorized by the office of [alcoholism
41 and substance abuse] addiction services and supports for the provision
42 of outpatient, intensive outpatient, outpatient rehabilitation and
43 opioid treatment that are participating in the insurer's provider
44 network. Coverage provided under this paragraph shall not be subject to
45 preauthorization. Coverage provided under this paragraph shall not be
46 subject to concurrent review for the first four weeks of continuous
47 treatment, not to exceed twenty-eight visits, provided the facility
48 notifies the insurer of both the start of treatment and the initial
49 treatment plan within two business days. The facility shall perform
50 clinical assessment of the patient at each visit, including periodic
51 consultation with the insurer at or just prior to the fourteenth day of
52 treatment to ensure that the facility is using the evidence-based and
53 peer reviewed clinical review tool utilized by the insurer which is
54 designated by the office of [alcoholism and substance abuse] addiction
55 services and supports and appropriate to the age of the patient, to
56 ensure that the outpatient treatment is medically necessary for the
S. 7288--A 3
1 patient. Any utilization review of the treatment provided under this
2 subparagraph may include a review of all services provided during such
3 outpatient treatment, including all services provided during the first
4 four weeks of continuous treatment, not to exceed twenty-eight visits,
5 of such outpatient treatment. Provided, however, the insurer shall only
6 deny coverage for any portion of the initial four weeks of continuous
7 treatment, not to exceed twenty-eight visits, for outpatient treatment
8 on the basis that such treatment was not medically necessary if such
9 outpatient treatment was contrary to the evidence-based and peer
10 reviewed clinical review tool utilized by the insurer which is desig-
11 nated by the office of [alcoholism and substance abuse] addiction
12 services and supports. An insured shall only have financial responsibil-
13 ities as set out in subparagraph (J) of this paragraph and shall not
14 have any financial obligation to the facility for any treatment under
15 this subparagraph other than any [copayment,] coinsurance[, or deduct-
16 ible] otherwise required under the policy.
17 (J) For a substance use disorder outpatient treatment episode of care
18 by a provider licensed, certified or otherwise authorized by the office
19 of addiction services and supports, an insured shall only be responsible
20 for a cost sharing fee not to exceed five hundred dollars. An insurer
21 providing coverage under this paragraph shall be responsible for all
22 other financial obligations to the facility. An episode of care is
23 defined to include up to sixty visits with the same treatment provider.
24 § 3. Paragraphs 3-a and 5 of subsection (l) of section 4303 of the
25 insurance law, paragraph 3-a as added by section 27 and paragraph 5 as
26 amended by section 28 of subpart A of part BB of chapter 57 of the laws
27 of 2019, are amended and a new paragraph 10 is added to read as follows:
28 (3-a) A contract that provides large group coverage under this
29 subsection shall not impose [copayments or] coinsurance for outpatient
30 substance use disorder services that exceed the [copayment or] coinsu-
31 rance imposed for a primary care office visit. [Provided that no greater
32 than one such copayment may be imposed for all services provided in a
33 single day by a facility licensed, certified or otherwise authorized by
34 the office of alcoholism and substance abuse services to provide outpa-
35 tient substance use disorder services] A large group policy that
36 provides coverage under this paragraph shall not impose copayments for
37 outpatient substance use disorder services.
38 (5) This paragraph shall apply to facilities in this state that are
39 licensed, certified or otherwise authorized by the office of [alcoholism
40 and substance abuse] addiction services and supports for the provision
41 of outpatient, intensive outpatient, outpatient rehabilitation and
42 opioid treatment that are participating in the corporation's provider
43 network. Coverage provided under this subsection shall not be subject to
44 preauthorization. Coverage provided under this subsection shall not be
45 subject to concurrent review for the first four weeks of continuous
46 treatment, not to exceed twenty-eight visits, provided the facility
47 notifies the corporation of both the start of treatment and the initial
48 treatment plan within two business days. The facility shall perform
49 clinical assessment of the patient at each visit, including periodic
50 consultation with the corporation at or just prior to the fourteenth day
51 of treatment to ensure that the facility is using the evidence-based and
52 peer reviewed clinical review tool utilized by the corporation which is
53 designated by the office of [alcoholism and substance abuse] addiction
54 services and supports and appropriate to the age of the patient, to
55 ensure that the outpatient treatment is medically necessary for the
56 patient. Any utilization review of the treatment provided under this
S. 7288--A 4
1 paragraph may include a review of all services provided during such
2 outpatient treatment, including all services provided during the first
3 four weeks of continuous treatment, not to exceed twenty-eight visits,
4 of such outpatient treatment. Provided, however, the corporation shall
5 only deny coverage for any portion of the initial four weeks of contin-
6 uous treatment, not to exceed twenty-eight visits, for outpatient treat-
7 ment on the basis that such treatment was not medically necessary if
8 such outpatient treatment was contrary to the evidence-based and peer
9 reviewed clinical review tool utilized by the corporation which is
10 designated by the office of [alcoholism and substance abuse] addiction
11 services and supports. A subscriber shall only have financial responsi-
12 bilities as set out in paragraph ten of this subsection and shall not
13 have any financial obligation to the facility for any treatment under
14 this paragraph other than any [copayment,] coinsurance[, or deductible]
15 otherwise required under the contract.
16 (10) For a substance use disorder outpatient treatment episode of care
17 by a provider licensed, certified or otherwise authorized by the office
18 of addiction services and supports, an insured shall only be responsible
19 for a cost sharing fee not to exceed five hundred dollars. An insurer
20 providing coverage under this paragraph shall be responsible for all
21 other financial obligations to the facility. An episode of care is
22 defined to include up to sixty visits with the same treatment provider.
23 § 4. This act shall take effect on the first of January next succeed-
24 ing the date on which it shall have become a law and shall apply to
25 policies and contracts issued, renewed, modified, altered or amended on
26 and after such date.