S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 7662--A

                            I N  S E N A T E

                              May 23, 2014
                               ___________

Introduced by Sens. SEWARD, HANNON, MARTINS, RITCHIE, BOYLE, BALL, BONA-
  CIC,  CARLUCCI,  FELDER,  GALLIVAN,  GOLDEN,  GRIFFO,  LANZA,  LARKIN,
  LAVALLE, LITTLE, MARCELLINO,  MARCHIONE,  MAZIARZ,  NOZZOLIO,  O'MARA,
  RANZENHOFER,  ROBACH, SAVINO, VALESKY, YOUNG -- read twice and ordered
  printed, and when printed to be committed to the Committee  on  Insur-
  ance  --  reported  favorably from said committee and committed to the
  Committee on Rules --  committee  discharged,  bill  amended,  ordered
  reprinted as amended and recommitted to said committee

AN ACT to amend the insurance law and the public health law, in relation
  to  requiring  health  insurance coverage for substance abuse disorder
  treatment services and creating a workgroup to study and  make  recom-
  mendations

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1.  Subsection (i) of section 3216 of  the  insurance  law  is
amended by adding a new paragraph 30 to read as follows:
  (30)  (A) EVERY POLICY THAT PROVIDES MEDICAL, MAJOR-MEDICAL OR SIMILAR
COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE FOR DRUG AND
ALCOHOL ABUSE AND DEPENDENCY TREATMENT SERVICES PURSUANT TO THE  FEDERAL
PAUL  WELLSTONE  AND  PETE  DOMENICI  MENTAL HEALTH PARITY AND ADDICTION
EQUITY ACT OF 2008, AND APPLICABLE STATE STATUTES WHICH REQUIRES  PARITY
BETWEEN   MENTAL   HEALTH   OR   SUBSTANCE  USE  DISORDER  BENEFITS  AND
MEDICAL/SURGICAL BENEFITS WITH RESPECT  TO  FINANCIAL  REQUIREMENTS  AND
TREATMENT.
  (B) DETERMINATION OF COVERAGE FOR SUBSTANCE ABUSE OR DEPENDENCY TREAT-
MENT  SERVICES  BY A HEALTH PLAN SHALL BE MADE THROUGH A MEDICAL MANAGE-
MENT REVIEW PROCESS WHICH:
  (I) UTILIZES A HEALTH CARE  PROVIDER  WHO  SPECIALIZES  IN  BEHAVIORAL
HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY OF SUBSTANCE ABUSE COURSES
OF  TREATMENT  TO SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS
RELATING TO SUBSTANCE ABUSE TREATMENT; AND
  (II) UTILIZES ONLY CLINICAL REVIEW  CRITERIA  CONTAINED  IN  THE  MOST
RECENT  EDITION  OF THE AMERICAN SOCIETY OF ADDICTION MEDICINE'S PATIENT
PLACEMENT CRITERIA OR OTHER RECOGNIZED AND  PEER  REVIEWED  CRITERIA  OR

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

                                                           LBD15361-03-4

S. 7662--A                          2

COMPENDIA  DEEMED APPROPRIATE AND APPROVED FOR SUCH USE BY THE OFFICE OF
ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMIS-
SIONER OF HEALTH AND THE SUPERINTENDENT. ANY ADDITIONAL  CRITERIA  SHALL
BE SUBJECT TO THE APPROVAL OF THE COMMISSIONER OF THE OFFICE OF ALCOHOL-
ISM  AND  SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMISSIONER
OF HEALTH AND SUPERINTENDENT.
  (C) THE LOCATION OF COVERED TREATMENT PURSUANT TO THIS  SECTION  SHALL
BE  SUBJECT TO THE INSURER'S REQUIREMENTS RELATING TO THE USE OF PARTIC-
IPATING PROVIDERS, INCLUDING THOSE  PROVIDERS  LOCATED  OUTSIDE  OF  THE
STATE.
  (D)  WHERE AN INSURED'S HEALTHCARE PROVIDER DETERMINES THAT A DELAY IN
PROVIDING CARE OF TREATMENT RELATING TO A SUBSTANCE USE  DISORDER  WOULD
POSE A SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE INSURED, ALL INTER-
NAL  AND  EXTERNAL APPEALS OF UTILIZATION REVIEW DETERMINATIONS SHALL BE
CONDUCTED ON AN EXPEDITED BASIS, AS  SET  FORTH  IN  SUBSECTION  (B)  OF
SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER AND IN PARAGRAPH
THREE  OF  SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN
OF THIS CHAPTER.
  (E) IN THE EVENT OF AN ADVERSE DETERMINATION FOR  SUBSTANCE  ABUSE  OR
DEPENDENCY TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE
COVERAGE  AND  REIMBURSE  FOR  ALL  SUCH  SERVICES UNTIL THE INSURED HAS
EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES
THE HEALTH PLAN IN WRITING THAT HE  OR  SHE  HAS  DECIDED  TO  NOT  MOVE
FORWARD WITH THE APPEALS PROCESS.
  (F)  FOR  PURPOSES  OF  THIS  SECTION:  "SUBSTANCE ABUSE OR DEPENDENCY
TREATMENT SERVICES" SHALL INCLUDE, BUT  NOT  LIMITED  TO,  HOSPITAL  AND
NON-HOSPITAL   BASED   DETOXIFICATION,   INCLUDING   MEDICALLY  MANAGED,
MEDICALLY SUPERVISED AND MEDICALLY MONITORED WITHDRAWAL,  INPATIENT  AND
RESIDENTIAL   REHABILITATION,  INTENSIVE  AND  NON-INTENSIVE  OUTPATIENT
TREATMENT, AND OUTPATIENT OPIOID TREATMENT PROGRAMS.
  S 2. Subsection (l) of section 3221 of the insurance law is amended by
adding a new paragraph 19 to read as follows:
  (19) (A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR  DELIV-
ERY  IN  THIS  STATE  WHICH PROVIDES MAJOR MEDICAL OR SIMILAR COMPREHEN-
SIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE FOR DRUG AND  ALCOHOL
ABUSE  AND  DEPENDENCY  TREATMENT  SERVICES PURSUANT TO THE FEDERAL PAUL
WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY  AND  ADDICTION  EQUITY
ACT OF 2008, AND APPLICABLE STATE STATUTES WHICH REQUIRES PARITY BETWEEN
MENTAL  HEALTH  OR  SUBSTANCE USE DISORDER BENEFITS AND MEDICAL/SURGICAL
BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND TREATMENT.
  (B) DETERMINATION OF COVERAGE FOR SUBSTANCE ABUSE OR DEPENDENCY TREAT-
MENT SERVICES BY A HEALTH PLAN SHALL BE MADE THROUGH A  MEDICAL  MANAGE-
MENT REVIEW PROCESS WHICH:
  (I)  UTILIZES  A  HEALTH  CARE  PROVIDER WHO SPECIALIZES IN BEHAVIORAL
HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY OF SUBSTANCE ABUSE COURSES
OF TREATMENT TO SUPERVISE AND OVERSEE THE MEDICAL  MANAGEMENT  DECISIONS
RELATING TO SUBSTANCE ABUSE TREATMENT; AND
  (II)  UTILIZES  ONLY  CLINICAL  REVIEW  CRITERIA CONTAINED IN THE MOST
RECENT EDITION OF THE AMERICAN SOCIETY OF ADDICTION  MEDICINE'S  PATIENT
PLACEMENT  CRITERIA  OR  OTHER  RECOGNIZED AND PEER REVIEWED CRITERIA OR
COMPENDIA DEEMED APPROPRIATE AND APPROVED FOR SUCH USE BY THE OFFICE  OF
ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMIS-
SIONER  OF  HEALTH AND THE SUPERINTENDENT. ANY ADDITIONAL CRITERIA SHALL
BE SUBJECT TO THE APPROVAL OF THE COMMISSIONER OF THE OFFICE OF ALCOHOL-
ISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH  THE  COMMISSIONER
OF HEALTH AND THE SUPERINTENDENT.

S. 7662--A                          3

  (C)  THE  LOCATION OF COVERED TREATMENT PURSUANT TO THIS SECTION SHALL
BE SUBJECT TO THE INSURER'S REQUIREMENTS RELATING TO THE USE OF  PARTIC-
IPATING  PROVIDERS,  INCLUDING  THOSE  PROVIDERS  LOCATED OUTSIDE OF THE
STATE.
  (D)  WHERE AN INSURED'S HEALTHCARE PROVIDER DETERMINES THAT A DELAY IN
PROVIDING CARE TO TREATMENT RELATING TO A SUBSTANCE USE  DISORDER  WOULD
POSE A SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE INSURED, ALL INTER-
NAL  AND  EXTERNAL APPEALS OF UTILIZATION REVIEW DETERMINATIONS SHALL BE
CONDUCTED ON AN EXPEDITED BASIS, AS  SET  FORTH  IN  SUBSECTION  (B)  OF
SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER AND IN PARAGRAPH
THREE  OF  SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN
OF THIS CHAPTER.
  (E) IN THE EVENT OF AN ADVERSE DETERMINATION FOR  SUBSTANCE  ABUSE  OR
DEPENDENCY TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE
COVERAGE  AND  REIMBURSE  FOR  ALL  SUCH  SERVICES UNTIL THE INSURED HAS
EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES
THE HEALTH PLAN IN WRITING THAT HE  OR  SHE  HAS  DECIDED  TO  NOT  MOVE
FORWARD WITH THE APPEALS PROCESS.
  (F)  FOR  PURPOSES  OF  THIS  SECTION:  "SUBSTANCE ABUSE OR DEPENDENCY
TREATMENT SERVICES" SHALL INCLUDE, BUT NOT BE LIMITED TO,  HOSPITAL  AND
NON-HOSPITAL   BASED   DETOXIFICATION,   INCLUDING   MEDICALLY  MANAGED,
MEDICALLY SUPERVISED AND MEDICALLY MONITORED WITHDRAWAL,  INPATIENT  AND
RESIDENTIAL   REHABILITATION,  INTENSIVE  AND  NON-INTENSIVE  OUTPATIENT
TREATMENT, AND OUTPATIENT OPIOID TREATMENT PROGRAMS.
  S 3. Section 4303 of the insurance law is  amended  by  adding  a  new
subsection (oo) to read as follows:
  (OO)  (1)  A MEDICAL EXPENSE INDEMNITY CORPORATION, A HOSPITAL SERVICE
CORPORATION OR A HEALTH SERVICE CORPORATION WHICH PROVIDES MAJOR MEDICAL
OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE  SPECIFIC  COVERAGE
FOR DRUG AND ALCOHOL ABUSE AND DEPENDENCY TREATMENT SERVICES PURSUANT TO
THE  FEDERAL  PAUL  WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND
ADDICTION EQUITY  ACT  OF  2008,  AND  APPLICABLE  STATE  STATUES  WHICH
REQUIRES PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS
AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND
TREATMENT.
  (2) DETERMINATION OF COVERAGE FOR SUBSTANCE ABUSE OR DEPENDENCY TREAT-
MENT  SERVICES  BY A HEALTH PLAN SHALL BE MADE THROUGH A MEDICAL MANAGE-
MENT REVIEW PROCESS WHICH:
  (I) UTILIZES A HEALTH CARE  PROVIDER  WHO  SPECIALIZES  IN  BEHAVIORAL
HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY OF SUBSTANCE ABUSE COURSES
OF  TREATMENT  TO SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS
RELATING TO SUBSTANCE ABUSE TREATMENT; AND
  (II) UTILIZES ONLY CLINICAL REVIEW  CRITERIA  CONTAINED  IN  THE  MOST
RECENT  EDITION  OF THE AMERICAN SOCIETY OF ADDICTION MEDICINE'S PATIENT
PLACEMENT CRITERIA OR OTHER RECOGNIZED AND  PEER  REVIEWED  CRITERIA  OR
COMPENDIA  DEEMED APPROPRIATE AND APPROVED FOR SUCH USE BY THE OFFICE OF
ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMIS-
SIONER OF HEALTH AND THE SUPERINTENDENT. ANY ADDITIONAL  CRITERIA  SHALL
BE SUBJECT TO THE APPROVAL OF THE COMMISSIONER OF THE OFFICE OF ALCOHOL-
ISM  AND  SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMISSIONER
OF HEALTH AND THE SUPERINTENDENT.
  (3) THE LOCATION OF COVERED TREATMENT PURSUANT TO THIS  SECTION  SHALL
BE  SUBJECT TO THE INSURER'S REQUIREMENTS RELATING TO THE USE OF PARTIC-
IPATING PROVIDERS, INCLUDING THOSE  PROVIDERS  LOCATED  OUTSIDE  OF  THE
STATE.

S. 7662--A                          4

  (4)  WHERE AN INSURED'S HEALTHCARE PROVIDER DETERMINES THAT A DELAY IN
PROVIDING CARE OR TREATMENT RELATING TO A SUBSTANCE USE  DISORDER  WOULD
POSE A SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE INSURED, ALL INTER-
NAL  AND EXTERNAL APPEALS OF THE UTILIZATION REVIEW DETERMINATIONS SHALL
BE  CONDUCTED  ON  AN EXPEDITED BASIS, AS SET FORTH IN SUBSECTION (B) OF
SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER AND IN PARAGRAPH
THREE OF SUBSECTION (B) OF SECTION FOUR THOUSAND NINE  HUNDRED  FOURTEEN
OF THIS CHAPTER.
  (5)  IN  THE  EVENT OF AN ADVERSE DETERMINATION FOR SUBSTANCE ABUSE OR
DEPENDENCY TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE
COVERAGE AND REIMBURSE FOR ALL  SUCH  SERVICES  UNTIL  THE  INSURED  HAS
EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES
THE  HEALTH  PLAN  IN  WRITING  THAT  HE  OR SHE HAS DECIDED TO NOT MOVE
FORWARD WITH THE APPEALS PROCESS.
  (6) FOR PURPOSES OF  THIS  SECTION:  "SUBSTANCE  ABUSE  OR  DEPENDENCY
TREATMENT  SERVICES"  SHALL INCLUDE, BUT NOT BE LIMITED TO, HOSPITAL AND
NON-HOSPITAL  BASED   DETOXIFICATION,   INCLUDING   MEDICALLY   MANAGED,
MEDICALLY  SUPERVISED  AND MEDICALLY MONITORED WITHDRAWAL, INPATIENT AND
RESIDENTIAL  REHABILITATION,  INTENSIVE  AND  NON-INTENSIVE   OUTPATIENT
TREATMENT, AND OUTPATIENT OPIOID TREATMENT PROGRAMS.
  S  4.  Section  4902 of the insurance law is amended by adding two new
subsections (c) and (d) to read as follows:
  (C) WHEN CONDUCTING  MEDICAL  MANAGEMENT  OR  UTILIZATION  REVIEW  FOR
PURPOSES  OF  DETERMINING  HEALTH CARE COVERAGE FOR SUBSTANCE USE DISOR-
DERS, A UTILIZATION REVIEW AGENT SHALL USE A HEALTH  CARE  PROVIDER  WHO
SPECIALIZES  IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY
OF SUBSTANCE USE DISORDER COURSES OF TREATMENT TO SUPERVISE AND  OVERSEE
THE  MEDICAL MANAGEMENT DECISIONS RELATING TO SUBSTANCE ABUSE TREATMENT.
IN ADDITION, A UTILIZATION REVIEW  AGENT  SHALL  UTILIZE  ONLY  CLINICAL
REVIEW  CRITERIA  CONTAINED  IN  THE MOST RECENT EDITION OF THE AMERICAN
SOCIETY OF ADDICTION MEDICINE'S  PATIENT  PLACEMENT  CRITERIA  OR  OTHER
RECOGNIZED  AND  PEER  REVIEWED  CRITERIA  OR COMPENDIA WHICH ARE DEEMED
APPROPRIATE AND APPROVED FOR SUCH USE BY THE COMMISSIONER OF THE  OFFICE
OF  ALCOHOLISM  AND  SUBSTANCE  ABUSE  SERVICES IN CONSULTATION WITH THE
COMMISSIONER OF HEALTH AND THE SUPERINTENDENT. ANY  ADDITIONAL  CRITERIA
SHALL  BE  SUBJECT  TO  THE  APPROVAL  OF  THE  OFFICE OF ALCOHOLISM AND
SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMISSIONER OF HEALTH
AND THE SUPERINTENDENT.
  (D) WHERE AN INSURED'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN
PROVIDING SUBSTANCE USE DISORDER TREATMENT WOULD POSE A  SERIOUS  THREAT
TO THE HEALTH OR SAFETY OF THE INSURED, INTERNAL AND EXTERNAL APPEALS OF
UTILIZATION  REVIEW  DETERMINATION  WILL  BE  CONDUCTED  ON AN EXPEDITED
BASIS, AS SET FORTH IN SUBSECTION (B)  OF  SECTION  FOUR  THOUSAND  NINE
HUNDRED FOUR OF THIS ARTICLE AND IN PARAGRAPH THREE OF SUBSECTION (B) OF
SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
  S  5.  Subsection (c) of section 4903 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (c) A utilization review agent shall make  a  determination  involving
continued  or  extended health care services, additional services for an
insured undergoing a course  of  continued  treatment  prescribed  by  a
health  care  provider,  or home health care services following an inpa-
tient hospital admission, and shall provide notice of such determination
to the insured or the insured's designee,  which  may  be  satisfied  by
notice  to the insured's health care provider, by telephone and in writ-
ing within one business day of  receipt  of  the  necessary  information
except, with respect to home health care services following an inpatient

S. 7662--A                          5

hospital admission OR REQUESTS FOR TREATMENT FOR SUBSTANCE USE DISORDER,
within  seventy-two  hours  of receipt of the necessary information when
the day subsequent to the request falls on a weekend or holiday. Notifi-
cation  of  continued  or  extended services shall include the number of
extended services approved, the new total of approved services, the date
of onset of services and the next review date. Provided that  a  request
for home health care services and all necessary information is submitted
to  the  utilization  review  agent prior to discharge from an inpatient
hospital admission pursuant to this  subsection,  a  utilization  review
agent shall not deny, on the basis of medical necessity or lack of prior
authorization,  coverage  for home health care services while a determi-
nation by the utilization review  agent  is  pending.  PROVIDED  THAT  A
REQUEST  FOR  TREATMENT  FOR  SUBSTANCE  USE  DISORDER AND ALL NECESSARY
INFORMATION IS SUBMITTED TO THE  UTILIZATION  REVIEW  PURSUANT  TO  THIS
SUBSECTION,  A  UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF
MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR SUBSTANCE
ABUSE OR DEPENDENCY TREATMENT WHILE A DETERMINATION BY  THE  UTILIZATION
REVIEW AGENT IS PENDING.
  S  6.  Subsection (b) of section 4904 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows
  (b) A utilization review agent shall  establish  an  expedited  appeal
process  for  appeal of an adverse determination involving (1) continued
or extended health care services, procedures or treatments or additional
services for an insured  undergoing  a  course  of  continued  treatment
prescribed  by  a  health  care  provider  or  home health care services
following discharge from an inpatient  hospital  admission  pursuant  to
subsection (c) of section four thousand nine hundred three of this arti-
cle  or  (2)  an adverse determination in which the health care provider
believes an immediate  appeal  is  warranted  except  any  retrospective
determination.  Such  process  shall include mechanisms which facilitate
resolution of the appeal including but not limited  to  the  sharing  of
information  from the insured's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent shall provide reasonable access  to  its  clinical  peer  reviewer
within  one  business  day of receiving notice of the taking of an expe-
dited appeal. Expedited appeals shall be determined within two  business
days  of  receipt of necessary information to conduct such appeal. Expe-
dited appeals which do not result in a resolution  satisfactory  to  the
appealing  party  may  be  further  appealed through the standard appeal
process, or through the external appeal process pursuant to section four
thousand nine hundred fourteen of this article as  applicable.  PROVIDED
THAT  THE  INSURED  OR  THE  INSURED'S HEALTH CARE PROVIDER NOTIFIES THE
UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL  IMME-
DIATELY  UPON  RECEIPT  OF  AN APPEAL DETERMINATION AND A REQUEST FOR AN
EXPEDITED EXTERNAL APPEAL FOR TREATMENT OF SUBSTANCE  USE  DISORDER  AND
ALL  NECESSARY  INFORMATION  IS  SUBMITTED  WITHIN  TWENTY-FOUR HOURS OF
RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION REVIEW AGENT SHALL NOT
DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR  AUTHORIZATION,
COVERAGE FOR SUCH TREATMENT WHILE A DETERMINATION BY THE EXTERNAL REVIEW
AGENT IS PENDING.
  S  7.  Section  4902 of the public health law is amended by adding two
new subdivisions 3 and 4 to read as follows:
  3. WHEN  CONDUCTING  MEDICAL  MANAGEMENT  OR  UTILIZATION  REVIEW  FOR
PURPOSES OF DETERMINING HEALTH CARE COVERAGE FOR SUBSTANCE USE DISORDER,
A UTILIZATION REVIEW AGENT SHALL USE A HEALTH CARE PROVIDER WHO SPECIAL-
IZES  IN  BEHAVIORAL  HEALTH  AND  WHO HAS EXPERIENCE IN THE DELIVERY OF

S. 7662--A                          6

SUBSTANCE USE DISORDER COURSES OF TREATMENT TO SUPERVISE AND OVERSEE THE
MEDICAL MANAGEMENT DECISIONS RELATING TO SUBSTANCE ABUSE  TREATMENT.  IN
ADDITION,  A UTILIZATION REVIEW AGENT SHALL UTILIZE ONLY CLINICAL REVIEW
CRITERIA CONTAINED IN THE MOST RECENT EDITION OF THE AMERICAN SOCIETY OF
ADDICTION  MEDICINE'S PATIENT PLACEMENT CRITERIA OR OTHER RECOGNIZED AND
PEER REVIEWED CRITERIA OR COMPENDIA WHICH  ARE  DEEMED  APPROPRIATE  AND
APPROVED  FOR  SUCH  USE BY THE COMMISSIONER OF THE OFFICE OF ALCOHOLISM
AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE  COMMISSIONER  AND
THE  SUPERINTENDENT  OF  THE DEPARTMENT OF FINANCIAL SERVICES. ANY ADDI-
TIONAL CRITERIA SHALL BE SUBJECT TO THE APPROVAL OF THE OFFICE OF  ALCO-
HOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMISSION-
ER AND THE SUPERINTENDENT OF THE DEPARTMENT OF FINANCIAL SERVICES.
  4. WHERE AN ENROLLEE'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN
PROVIDING  SUBSTANCE  USE DISORDER TREATMENT WOULD POSE A SERIOUS THREAT
TO THE HEALTH OR SAFETY OF THE ENROLLEE, INTERNAL AND  EXTERNAL  APPEALS
OF  UTILIZATION  REVIEW DETERMINATIONS WILL BE CONDUCTED ON AN EXPEDITED
BASIS, AS SET FORTH IN SUBDIVISION TWO OF  SECTION  FOUR  THOUSAND  NINE
HUNDRED  FOUR OF THIS ARTICLE AND IN PARAGRAPH (C) OF SUBDIVISION TWO OF
SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
  S 8. Subdivision 3 of section  4903  of  the  public  health  law,  as
amended  by  chapter  237  of  the  laws  of 2009, is amended to read as
follows:
  3. A utilization review agent shall  make  a  determination  involving
continued  or  extended health care services, additional services for an
enrollee undergoing a course of  continued  treatment  prescribed  by  a
health  care  provider,  or home health care services following an inpa-
tient hospital admission, and shall provide notice of such determination
to the enrollee or the enrollee's designee, which may  be  satisfied  by
notice to the enrollee's health care provider, by telephone and in writ-
ing  within  one  business  day  of receipt of the necessary information
except, with respect to home health care services following an inpatient
hospital admission, OR REQUESTS FOR TREATMENT FOR SUBSTANCE  USE  DISOR-
DER,  within  seventy-two  hours of receipt of the necessary information
when the day subsequent to the request falls on a  weekend  or  holiday.
Notification  of continued or extended services shall include the number
of extended services approved, the new total of approved  services,  the
date  of  onset  of  services  and the next review date. Provided that a
request for home health care services and all necessary  information  is
submitted  to  the  utilization  review agent prior to discharge from an
inpatient hospital admission pursuant to this subdivision, a utilization
review agent shall not deny, on the basis of medical necessity  or  lack
of  prior  authorization, coverage for home health care services while a
determination by the utilization review agent is pending.  PROVIDED THAT
A REQUEST FOR TREATMENT FOR SUBSTANCE USE  DISORDER  AND  ALL  NECESSARY
INFORMATION  IS  SUBMITTED  TO  THE UTILIZATION REVIEW AGENT PURSUANT TO
THIS SUBDIVISION, A UTILIZATION REVIEW AGENT  SHALL  NOT  DENY,  ON  THE
BASIS  OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR
SUBSTANCE ABUSE OR DEPENDENCY TREATMENT SERVICES WHILE  A  DETERMINATION
BY THE UTILIZATION REVIEW AGENT IS PENDING.
  S  9.  Subdivision  2  of  section  4904  of the public health law, as
amended by chapter 237 of the laws  of  2009,  is  amended  to  read  as
follows:
  2.  A  utilization  review  agent  shall establish an expedited appeal
process for appeal of an adverse determination involving:
  (a) continued or extended health care services, procedures  or  treat-
ments  or  additional  services  for  an enrollee undergoing a course of

S. 7662--A                          7

continued treatment prescribed by a health  care  provider  home  health
care  services  following discharge from an inpatient hospital admission
pursuant to subdivision three of section  forty-nine  hundred  three  of
this article; or
  (b)  an  adverse  determination  in  which  the  health  care provider
believes an immediate  appeal  is  warranted  except  any  retrospective
determination.    Such process shall include mechanisms which facilitate
resolution of the appeal including but not limited  to  the  sharing  of
information from the enrollee's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent  shall  provide  reasonable  access  to its clinical peer reviewer
within one business day of receiving notice of the taking  of  an  expe-
dited appeal.  Expedited appeals shall be determined within two business
days  of  receipt of necessary information to conduct such appeal. Expe-
dited appeals which do not result in a resolution  satisfactory  to  the
appealing  party  may  be  further  appealed through the standard appeal
process, or through the external  appeal  process  pursuant  to  section
forty-nine  hundred  fourteen  of  this article as applicable.  PROVIDED
THAT THE INSURED OR THE INSURED'S  HEALTH  CARE  PROVIDER  NOTIFIES  THE
UTILIZATION  REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME-
DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND  A  REQUEST  FOR  AN
EXPEDITED  EXTERNAL  APPEAL  FOR TREATMENT OF SUBSTANCE USE DISORDER AND
ALL NECESSARY INFORMATION  IS  SUBMITTED  WITHIN  TWENTY-FOUR  HOURS  OF
RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION REVIEW AGENT SHALL NOT
DENY,  ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION,
COVERAGE FOR SUCH TREATMENT WHILE A DETERMINATION BY THE EXTERNAL REVIEW
AGENT IS PENDING.
  S 10. The superintendent of the department of financial services shall
select a random sampling of substance abuse treatment coverage  determi-
nations  and  provide  an analysis of whether or not such determinations
are in compliance with the criteria established in this act  and  report
its  finding to the governor, the temporary president of the senate, and
speaker of the assembly, the chairs of the senate and assembly insurance
committees, and the chairs of the senate and assembly health  committees
no later than December 31, 2015.
  S  11.  1.  Within  thirty days of the effective date of this act, the
commissioner of the office of alcoholism and substance  abuse  services,
superintendent  of the department of financial services, and the commis-
sioner of health, shall jointly convene a workgroup to  study  and  make
recommendations  on  improving  access  to and availability of substance
abuse and dependency treatment services  in  the  state.  The  workgroup
shall  be co-chaired by such commissioners and superintendent, and shall
also include, but not be limited  to,  representatives  of  health  care
providers,  insurers, additional professionals, individuals and families
who have been affected by addiction. The workgroup  shall  include,  but
not be limited to, a review of the following:
  a.  Identifying barriers to obtaining necessary substance abuse treat-
ment services for across the state;
  b. Recommendations  for  increasing  access  to  and  availability  of
substance  abuse  treatment services in the state, including underserved
areas of the state;
  c. Identifying best clinical practices for substance  abuse  treatment
services;
  d. A review of current insurance coverage requirements and recommenda-
tions for improving insurance coverage for substance abuse and dependen-
cy treatment;

S. 7662--A                          8

  e.  Recommendations  for  improving  state  agency  communication  and
collaboration relating to substance  abuse  treatment  services  in  the
state;
  f.  Resources  for  affected  individuals  and families who are having
difficulties obtaining necessary substance abuse treatment services; and
  g. Methods for developing quality standards to measure the performance
of substance abuse treatment facilities in the state.
  2. The workgroup shall submit a report of its findings and recommenda-
tions to the governor, the temporary president of the senate, the speak-
er of the assembly, the chairs of  the  senate  and  assembly  insurance
committees,  and the chairs of the senate and assembly health committees
no later than December 31, 2015.
  S 12. This act shall take effect immediately.