Bill Text: NY S07352 | 2021-2022 | General Assembly | Introduced


Bill Title: Includes clinically necessary treatment for certain inpatient coverage, which shall mean an individual's medical needs and any social determinants of health that will promote such individual's stability following discharge from treatment.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2022-01-05 - REFERRED TO INSURANCE [S07352 Detail]

Download: New_York-2021-S07352-Introduced.html



                STATE OF NEW YORK
        ________________________________________________________________________

                                          7352

                               2021-2022 Regular Sessions

                    IN SENATE

                                     August 27, 2021
                                       ___________

        Introduced  by Sen. HARCKHAM -- read twice and ordered printed, and when
          printed to be committed to the Committee on Rules

        AN ACT to amend the insurance law, in relation to  including  clinically
          necessary treatment for certain inpatient coverage

          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:

     1    Section 1. Paragraph 30 of subsection  (i)  of  section  3216  of  the
     2  insurance  law, as amended by section 5 of subpart A of part BB of chap-
     3  ter 57 of the laws of 2019, is amended to read as follows:
     4    (30)(A) Every policy that provides hospital, major medical or  similar
     5  comprehensive  coverage shall provide inpatient coverage for the diagno-
     6  sis and treatment of substance use  disorder,  including  detoxification
     7  and rehabilitation services. Such inpatient coverage [shall] may include
     8  [unlimited  medically]  clinically necessary treatment for substance use
     9  disorder treatment services provided  in  residential  settings  at  the
    10  discretion  of  the  service  provider. Further, such inpatient coverage
    11  shall not apply financial requirements or treatment limitations, includ-
    12  ing utilization review requirements, to inpatient substance use disorder
    13  benefits that  are  more  restrictive  than  the  predominant  financial
    14  requirements  and  treatment  limitations  applied  to substantially all
    15  medical and surgical benefits covered by the policy.
    16    (B) Coverage provided under this paragraph may be limited  to  facili-
    17  ties in New York state that are licensed, certified or otherwise author-
    18  ized  by  the  office  of  [alcoholism  and  substance  abuse] addiction
    19  services and supports and, in other states, to those which  are  accred-
    20  ited by the joint commission as alcoholism, substance abuse, or chemical
    21  dependence  treatment  programs and are similarly licensed, certified or
    22  otherwise authorized in the state in which the facility is located.
    23    (C) Coverage provided under this paragraph may be  subject  to  annual
    24  deductibles and co-insurance as deemed appropriate by the superintendent

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD13063-02-1

        S. 7352                             2

     1  and  that  are  consistent with those imposed on other benefits within a
     2  given policy.
     3    (D) This subparagraph shall apply to facilities in this state that are
     4  licensed, certified or otherwise authorized by the office of [alcoholism
     5  and  substance  abuse]  addiction services and supports that are partic-
     6  ipating in the insurer's provider network. Coverage provided under  this
     7  paragraph  shall  not  be subject to preauthorization. Coverage provided
     8  under this paragraph shall also not be subject to concurrent utilization
     9  review during the first twenty-eight days  of  the  inpatient  admission
    10  provided  that  the  facility notifies the insurer of both the admission
    11  and the initial treatment plan within two business days  of  the  admis-
    12  sion.  The  facility shall perform daily clinical review of the patient,
    13  including periodic consultation with the insurer at or just prior to the
    14  fourteenth day of treatment to ensure that the  facility  is  using  the
    15  evidence-based  and  peer  reviewed clinical review tool utilized by the
    16  insurer which is designated by the office of [alcoholism  and  substance
    17  abuse] addiction services and supports and appropriate to the age of the
    18  patient,  to  ensure  that  the inpatient treatment is [medically] clin-
    19  ically necessary for the patient. Prior to discharge, the facility shall
    20  provide the patient and the insurer with a written discharge plan  which
    21  shall  describe  arrangements  for  additional services needed following
    22  discharge from the inpatient facility as determined using the  evidence-
    23  based  and  peer-reviewed  clinical  review tool utilized by the insurer
    24  which is designated by the office of [alcoholism  and  substance  abuse]
    25  addiction services and supports.  Prior to discharge, the facility shall
    26  indicate  to the insurer whether services included in the discharge plan
    27  are secured or determined to be reasonably  available.  Any  utilization
    28  review  of  treatment  provided  under  this  subparagraph may include a
    29  review of all services provided during such inpatient treatment, includ-
    30  ing all services provided during the first  twenty-eight  days  of  such
    31  inpatient  treatment.  Provided,  however, [the] such utilization review
    32  shall only be imposed to  the  extent  the  insurer's  requirements  are
    33  permitted  under  the  federal  Paul  Wellstone and Pete Domenici Mental
    34  Health Parity and Addiction Equity Act  of  2008  and  applicable  regu-
    35  lations  (29  U.S.C. § 1185a; 42 U.S.C. § 300gg-26; 45 C.F.R. Parts 146,
    36  147). The insurer [shall] may only deny coverage for any portion of  the
    37  initial  twenty-eight  day  inpatient  treatment  on the basis that such
    38  treatment was not [medically] clinically  necessary  if  such  inpatient
    39  treatment was [contrary to] not indicated by the evidence-based and peer
    40  reviewed  clinical  review  tool utilized by the insurer which is desig-
    41  nated by the  office  of  [alcoholism  and  substance  abuse]  addiction
    42  services  and supports.   Any denial must specifically identify: (i) how
    43  such treatment was not indicated by the office of addiction services and
    44  supports designated clinical  review  tool;  and  (ii)  how  the  policy
    45  applied the office of addiction services and supports designated tool to
    46  the outpatient substance use disorder care in a manner comparable to and
    47  no  more  stringent than the policy's application of its clinical review
    48  tool for outpatient medical and surgical benefits covered by the policy.
    49  Any concurrent or retrospective review imposed  by  the  plan,  both  as
    50  written  and  as applied, must be consistent with the federal Paul Well-
    51  stone and Pete Domenici Mental Health Parity and Addiction Equity Act of
    52  2008 and applicable regulations (29 U.S.C. § 1185a; 42 U.S.C.  §  300gg-
    53  26;  45  C.F.R. Parts 146, 147). An insured shall not have any financial
    54  obligation to the facility for any  treatment  under  this  subparagraph
    55  other  than any copayment, coinsurance, or deductible otherwise required
    56  under the policy.

        S. 7352                             3

     1    (E) An insurer  shall  make  available  to  any  insured,  prospective
     2  insured,   or  in-network  provider,  upon  request,  the  criteria  for
     3  [medical]  clinical  necessity  determinations  under  the  policy  with
     4  respect to inpatient substance use disorder benefits.
     5    (F) For purposes of this paragraph:
     6    (i)  "financial requirement" means deductible, copayments, coinsurance
     7  and out-of-pocket expenses;
     8    (ii) "predominant" means that a  financial  requirement  or  treatment
     9  limitation  is  the  most  common  or  frequent of such type of limit or
    10  requirement;
    11    (iii) "treatment limitation" means limits on the frequency  of  treat-
    12  ment, number of visits, days of coverage, or other similar limits on the
    13  scope  or  duration  of treatment and includes nonquantitative treatment
    14  limitations such as: medical management standards limiting or  excluding
    15  benefits  based on [medical] clinical necessity, or based on whether the
    16  treatment is  experimental  or  investigational;  formulary  design  for
    17  prescription  drugs;  network tier design; standards for provider admis-
    18  sion to participate in a network, including reimbursement rates; methods
    19  for determining usual, customary, and reasonable charges; fail-first  or
    20  step therapy protocols; exclusions based on failure to complete a course
    21  of  treatment;  and  restrictions based on geographic location, facility
    22  type, provider specialty, and other criteria that  limit  the  scope  or
    23  duration of benefits for services provided under the policy; [and]
    24    (iv)  "substance use disorder" shall have the meaning set forth in the
    25  most recent edition of the diagnostic and statistical manual  of  mental
    26  disorders  or  the  most  recent edition of another generally recognized
    27  independent standard of current medical practice, such as  the  interna-
    28  tional classification of diseases[.]; and
    29    (v)  "clinical necessity" means both an individual's medical needs and
    30  any social determinants of health that will  promote  such  individual's
    31  stability following discharge from treatment.
    32    (G) An insurer shall provide coverage under this paragraph, at a mini-
    33  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    34  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    35    § 2. This act shall take effect immediately.
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