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

    S. 7912                                                 A. 10164

                      S E N A T E - A S S E M B L Y

                              June 17, 2014
                               ___________

IN SENATE -- Introduced by Sens. SEWARD, HANNON, MARTINS, RITCHIE -- (at
  request  of  the Governor) -- read twice and ordered printed, and when
  printed to be committed to the Committee on Rules

IN ASSEMBLY -- Introduced by COMMITTEE ON RULES -- (at request of M.  of
  A.  Cusick)  -- (at request of the Governor) -- read once and referred
  to the Committee on Insurance

AN ACT to amend the insurance law and the public health law, in relation
  to requiring health insurance  coverage  for  substance  use  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 two new paragraphs 30 and 31 to read as follows:
  (30)(A) EVERY POLICY THAT PROVIDES HOSPITAL, MAJOR MEDICAL OR  SIMILAR
COMPREHENSIVE COVERAGE MUST PROVIDE INPATIENT COVERAGE FOR THE DIAGNOSIS
AND  TREATMENT  OF  SUBSTANCE USE DISORDER, INCLUDING DETOXIFICATION AND
REHABILITATION  SERVICES.  SUCH  COVERAGE  SHALL  NOT  APPLY   FINANCIAL
REQUIREMENTS  OR TREATMENT LIMITATIONS TO INPATIENT SUBSTANCE USE DISOR-
DER BENEFITS THAT ARE MORE RESTRICTIVE THAN  THE  PREDOMINANT  FINANCIAL
REQUIREMENTS  AND  TREATMENT  LIMITATIONS  APPLIED  TO SUBSTANTIALLY ALL
MEDICAL AND SURGICAL BENEFITS COVERED BY  THE  POLICY.    FURTHER,  SUCH
COVERAGE  SHALL  BE  PROVIDED CONSISTENT WITH THE FEDERAL PAUL WELLSTONE
AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF  2008
(29 U.S.C. S 1185A).
  (B)  COVERAGE  PROVIDED UNDER THIS PARAGRAPH MAY BE LIMITED TO FACILI-
TIES IN NEW YORK STATE WHICH ARE CERTIFIED BY THE OFFICE  OF  ALCOHOLISM
AND  SUBSTANCE  ABUSE  SERVICES AND, IN OTHER STATES, TO THOSE WHICH ARE
ACCREDITED BY THE JOINT COMMISSION AS ALCOHOLISM,  SUBSTANCE  ABUSE,  OR
CHEMICAL DEPENDENCE TREATMENT PROGRAMS.
  (C)  COVERAGE  PROVIDED  UNDER THIS PARAGRAPH MAY BE SUBJECT TO ANNUAL
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.
                                                           LBD12108-01-4
              

S. 7912                             2                           A. 10164

AND THAT ARE CONSISTENT WITH THOSE IMPOSED ON OTHER  BENEFITS  WITHIN  A
GIVEN POLICY.
  (31)  (A) EVERY POLICY THAT PROVIDES MEDICAL, MAJOR MEDICAL OR SIMILAR
COMPREHENSIVE-TYPE COVERAGE MUST PROVIDE  OUTPATIENT  COVERAGE  FOR  THE
DIAGNOSIS AND TREATMENT OF SUBSTANCE USE DISORDER, INCLUDING DETOXIFICA-
TION  AND  REHABILITATION SERVICES. SUCH COVERAGE SHALL NOT APPLY FINAN-
CIAL REQUIREMENTS OR TREATMENT LIMITATIONS TO OUTPATIENT  SUBSTANCE  USE
DISORDER  BENEFITS THAT ARE MORE RESTRICTIVE THAN THE PREDOMINANT FINAN-
CIAL REQUIREMENTS AND TREATMENT LIMITATIONS APPLIED TO SUBSTANTIALLY ALL
MEDICAL AND SURGICAL BENEFITS  COVERED  BY  THE  POLICY.  FURTHER,  SUCH
COVERAGE  SHALL  BE  PROVIDED CONSISTENT WITH THE FEDERAL PAUL WELLSTONE
AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF  2008
(29 U.S.C. S 1185A).
  (B)  COVERAGE UNDER THIS PARAGRAPH MAY BE LIMITED TO FACILITIES IN NEW
YORK STATE CERTIFIED BY THE OFFICE OF  ALCOHOLISM  AND  SUBSTANCE  ABUSE
SERVICES  OR  LICENSED BY SUCH OFFICE AS OUTPATIENT CLINICS OR MEDICALLY
SUPERVISED AMBULATORY SUBSTANCE ABUSE PROGRAMS AND, IN OTHER STATES,  TO
THOSE  WHICH  ARE  ACCREDITED  BY  THE JOINT COMMISSION AS ALCOHOLISM OR
CHEMICAL DEPENDENCE SUBSTANCE ABUSE TREATMENT PROGRAMS.
  (C) COVERAGE PROVIDED UNDER THIS PARAGRAPH MAY BE  SUBJECT  TO  ANNUAL
DEDUCTIBLES AND CO-INSURANCE AS DEEMED APPROPRIATE BY THE SUPERINTENDENT
AND  THAT  ARE  CONSISTENT WITH THOSE IMPOSED ON OTHER BENEFITS WITHIN A
GIVEN POLICY.
  (D) A POLICY PROVIDING COVERAGE FOR SUBSTANCE  USE  DISORDER  SERVICES
PURSUANT  TO THIS PARAGRAPH SHALL PROVIDE UP TO TWENTY OUTPATIENT VISITS
PER POLICY OR CALENDAR YEAR TO  AN  INDIVIDUAL  WHO  IDENTIFIES  HIM  OR
HERSELF  AS  A  FAMILY  MEMBER  OF A PERSON SUFFERING FROM SUBSTANCE USE
DISORDER AND WHO SEEKS TREATMENT AS A FAMILY  MEMBER  WHO  IS  OTHERWISE
COVERED  BY THE APPLICABLE POLICY PURSUANT TO THIS PARAGRAPH. THE COVER-
AGE REQUIRED BY THIS PARAGRAPH  SHALL  INCLUDE  TREATMENT  AS  A  FAMILY
MEMBER  PURSUANT TO SUCH FAMILY MEMBER'S OWN POLICY PROVIDED SUCH FAMILY
MEMBER:
  (I) DOES NOT EXCEED THE ALLOWABLE NUMBER OF FAMILY VISITS PROVIDED  BY
THE APPLICABLE POLICY PURSUANT TO THIS PARAGRAPH; AND
  (II)  IS OTHERWISE ENTITLED TO COVERAGE PURSUANT TO THIS PARAGRAPH AND
SUCH FAMILY MEMBER'S APPLICABLE POLICY.
  S 2. Paragraphs 6 and 7 of subsection  (l)  of  section  3221  of  the
insurance law, paragraph 6 as amended by chapter 558 of the laws of 1999
and  paragraph  7  as  amended  by  chapter 565 of the laws of 2000, are
amended to read as follows:
  (6) (A) Every [insurer delivering a group or school blanket policy  or
issuing  a  group  or school blanket policy for delivery, in this state,
which] POLICY THAT  provides  [coverage  for  inpatient  hospital  care]
HOSPITAL,  MAJOR  MEDICAL  OR  SIMILAR COMPREHENSIVE COVERAGE must [make
available and, if requested  by  the  policyholder,]  provide  INPATIENT
coverage for the diagnosis and treatment of [chemical abuse and chemical
dependence,  however defined in such policy, provided, however, that the
term chemical abuse shall mean and include alcohol and  substance  abuse
and  chemical dependence shall mean and include alcoholism and substance
dependence, however defined in such policy. Written notice of the avail-
ability of such coverage shall be delivered to the policyholder prior to
inception of such group policy and annually thereafter, except that this
notice shall not be required where a policy covers two hundred  or  more
employees  or  where the benefit structure was the subject of collective
bargaining affecting persons who are employed in more than one state.
  (B) Such coverage shall be at least equal to the following:

S. 7912                             3                           A. 10164

  (i) with respect to benefits for detoxification as  a  consequence  of
chemical  dependence,  inpatient benefits in a hospital or a detoxifica-
tion facility may not be limited to  less  than  seven  days  of  active
treatment in any calendar year; and
  (ii)  with respect to benefits for rehabilitation services, such bene-
fits may not be limited to less than thirty days of  inpatient  care  in
any calendar year.] SUBSTANCE USE DISORDER, INCLUDING DETOXIFICATION AND
REHABILITATION   SERVICES.  SUCH  COVERAGE  SHALL  NOT  APPLY  FINANCIAL
REQUIREMENTS OR TREATMENT LIMITATIONS TO INPATIENT SUBSTANCE USE  DISOR-
DER  BENEFITS  THAT  ARE MORE RESTRICTIVE THAN THE PREDOMINANT FINANCIAL
REQUIREMENTS AND TREATMENT  LIMITATIONS  APPLIED  TO  SUBSTANTIALLY  ALL
MEDICAL  AND  SURGICAL  BENEFITS  COVERED BY THE POLICY.   FURTHER, SUCH
COVERAGE SHALL BE PROVIDED CONSISTENT WITH THE  FEDERAL  PAUL  WELLSTONE
AND  PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008
(29 U.S.C. S 1185A).
  [(C) Such coverage] (B) COVERAGE PROVIDED UNDER THIS PARAGRAPH may  be
limited  to  facilities  in  New  York  state which are certified by the
office of alcoholism and substance abuse services and, in other  states,
to  those which are accredited by the joint commission [on accreditation
of hospitals] as alcoholism,  substance  abuse  or  chemical  dependence
treatment programs.
  [(D) Such coverage shall be made available at the inception of all new
policies  and with respect to all other policies at any anniversary date
of the policy subject to evidence of insurability.
  (E) Such coverage] (C) COVERAGE PROVIDED UNDER THIS PARAGRAPH  may  be
subject to annual deductibles and co-insurance as [may be] deemed appro-
priate  by the superintendent and THAT are consistent with those imposed
on other benefits within a given policy. [Further,  each  insurer  shall
report to the superintendent each year the number of contract holders to
whom  it  has  issued  policies  for the inpatient treatment of chemical
dependence, and the approximate number of persons covered by such  poli-
cies.
  (F)  Such  coverage  shall not replace, restrict or eliminate existing
coverage provided by the policy.]
  (7) (A) Every [insurer delivering a group or school blanket policy  or
issuing  a  group  or  school  blanket policy for delivery in this state
which] POLICY THAT  provides  [coverage  for  inpatient  hospital  care]
MEDICAL,  MAJOR  MEDICAL  OR  SIMILAR  COMPREHENSIVE-TYPE  COVERAGE must
provide OUTPATIENT coverage for [at least sixty outpatient visits in any
calendar year for] the diagnosis and treatment of  [chemical  dependence
of  which  up  to  twenty  may  be  for family members, except that this
provision shall not apply to a policy which covers persons  employed  in
more than one state or the benefit structure of which was the subject of
collective  bargaining  affecting  persons who are employed in more than
one state.] SUBSTANCE USE DISORDER, INCLUDING DETOXIFICATION  AND  REHA-
BILITATION  SERVICES.  SUCH  COVERAGE SHALL NOT APPLY FINANCIAL REQUIRE-
MENTS OR TREATMENT LIMITATIONS  TO  OUTPATIENT  SUBSTANCE  USE  DISORDER
BENEFITS  THAT  ARE  MORE  RESTRICTIVE  THAN  THE  PREDOMINANT FINANCIAL
REQUIREMENTS AND TREATMENT  LIMITATIONS  APPLIED  TO  SUBSTANTIALLY  ALL
MEDICAL  AND  SURGICAL  BENEFITS  COVERED BY THE POLICY.   FURTHER, SUCH
COVERAGE SHALL BE PROVIDED CONSISTENT WITH THE  FEDERAL  PAUL  WELLSTONE
AND  PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008
(29 U.S.C. S 1185A).
  [Such coverage]  (B) COVERAGE UNDER THIS PARAGRAPH may be  limited  to
facilities  in  New York state certified by the office of alcoholism and
substance abuse services or licensed by such office as outpatient  clin-

S. 7912                             4                           A. 10164

ics  or medically supervised ambulatory substance abuse programs and, in
other states, to those which are accredited by the joint commission  [on
accreditation  of hospitals] as alcoholism or chemical dependence treat-
ment programs.
  [Such  coverage]  (C)  COVERAGE  PROVIDED  UNDER THIS PARAGRAPH may be
subject to annual deductibles and co-insurance as [may be] deemed appro-
priate by the superintendent and THAT are consistent with those  imposed
on  other  benefits  within  a  given  policy.  [Such coverage shall not
replace, restrict, or eliminate existing coverage provided by the  poli-
cy.  Except  as otherwise provided in the applicable policy or contract,
no insurer delivering a group or school  blanket  policy  or  issuing  a
group  or  school  blanket  policy  providing coverage for alcoholism or
substance abuse services pursuant to this section shall deny coverage to
a family member]
  (D) A POLICY PROVIDING COVERAGE FOR SUBSTANCE  USE  DISORDER  SERVICES
PURSUANT  TO THIS PARAGRAPH SHALL PROVIDE UP TO TWENTY OUTPATIENT VISITS
PER POLICY OR CALENDAR YEAR TO AN INDIVIDUAL who  identifies  [themself]
HIM  OR  HERSELF  as  a  family  member  of a person suffering from [the
disease of alcoholism, substance abuse or chemical dependency] SUBSTANCE
USE DISORDER and who seeks treatment as a family member who is otherwise
covered  by  the  applicable  policy  [or  contract]  pursuant  to  this
[section]  PARAGRAPH.    The  coverage  required by this paragraph shall
include treatment as a family member pursuant to such family  [members']
MEMBER'S own policy [or contract] provided such family member:
  (i)  does not exceed the allowable number of family visits provided by
the applicable policy [or contract] pursuant to  this  [section,]  PARA-
GRAPH; and
  (ii)  is  otherwise  entitled  to  coverage pursuant to this [section]
PARAGRAPH and such family  [members']  MEMBER'S  applicable  policy  [or
contract].
  S  3.  Subsections  (k)  and (l) of section 4303 of the insurance law,
subsection (k) as amended by  chapter  558  of  the  laws  of  1999  and
subsection  (l)  as  amended  by  chapter  565  of the laws of 2000, are
amended to read as follows:
  (k) [A hospital service corporation or a  health  service  corporation
which]  (1)  EVERY  CONTRACT  THAT  provides [group, group remittance or
school blanket coverage for inpatient  hospital  care]  HOSPITAL,  MAJOR
MEDICAL  OR  SIMILAR  COMPREHENSIVE COVERAGE must [make available and if
requested by the contract holder] provide  INPATIENT  coverage  for  the
diagnosis  and  treatment  of  [chemical  abuse and chemical dependence,
however defined in such policy, provided, however, that the term  chemi-
cal  abuse shall mean and include alcohol and substance abuse and chemi-
cal dependence shall mean and include alcoholism and  substance  depend-
ence,  however  defined in such policy, except that this provision shall
not apply to a policy which covers persons employed  in  more  than  one
state  or  the  benefit structure of which was the subject of collective
bargaining affecting persons who are employed in more  than  one  state.
Such coverage shall be at least equal to the following: (1) with respect
to  benefits for detoxification as a consequence of chemical dependence,
inpatient benefits for care in a hospital or detoxification facility may
not be limited to less than seven days of active treatment in any calen-
dar year; and (2) with respect to benefits for inpatient  rehabilitation
services,  such  benefits may not be limited to less than thirty days of
inpatient rehabilitation in a hospital based or free  standing  chemical
dependence  facility  in  any  calendar  year.]  SUBSTANCE USE DISORDER,
INCLUDING DETOXIFICATION AND REHABILITATION  SERVICES.    SUCH  COVERAGE

S. 7912                             5                           A. 10164

SHALL NOT APPLY FINANCIAL REQUIREMENTS OR TREATMENT LIMITATIONS TO INPA-
TIENT SUBSTANCE USE DISORDER BENEFITS THAT ARE MORE RESTRICTIVE THAN THE
PREDOMINANT  FINANCIAL REQUIREMENTS AND TREATMENT LIMITATIONS APPLIED TO
SUBSTANTIALLY ALL MEDICAL AND SURGICAL BENEFITS COVERED BY THE CONTRACT.
FURTHER,  SUCH  COVERAGE  SHALL  BE PROVIDED CONSISTENT WITH THE FEDERAL
PAUL WELLSTONE AND PETE DOMENICI  MENTAL  HEALTH  PARITY  AND  ADDICTION
EQUITY ACT OF 2008 (29 U.S.C. S 1185A).
  [Such  coverage]  (2)  COVERAGE  PROVIDED UNDER THIS SUBSECTION may be
limited to facilities in New York  state  which  are  certified  by  the
office  of alcoholism and substance abuse services and, in other states,
to those which are accredited by the joint commission [on  accreditation
of  hospitals]  as  alcoholism,  substance abuse, or chemical dependence
treatment programs. [Such coverage shall be made available at the incep-
tion of all new policies and with respect to policies issued before  the
effective  date  of this subsection at the first annual anniversary date
thereafter, without evidence of insurability and at any subsequent annu-
al anniversary date subject to evidence of insurability.
  Such coverage] (3) COVERAGE PROVIDED  UNDER  THIS  SUBSECTION  may  be
subject to annual deductibles and co-insurance as [may be] deemed appro-
priate  by the superintendent and THAT are consistent with those imposed
on other benefits within a given  [policy]  CONTRACT.    [Further,  each
hospital  service corporation or health service corporation shall report
to the superintendent each year the number of contract holders  to  whom
it  has  issued policies for the inpatient treatment of chemical depend-
ence, and the approximate number of persons covered  by  such  policies.
Such coverage shall not replace, restrict or eliminate existing coverage
provided  by  the  policy.  Written  notice  of the availability of such
coverage shall be delivered  to  the  group  remitting  agent  or  group
contract  holder prior to inception of such contract and annually there-
after, except that this notice shall not  be  required  where  a  policy
covers  two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are  employed
in more than one state.]
  (l)  [A  hospital  service corporation or a health service corporation
which] (1) EVERY CONTRACT THAT  provides  [group,  group  remittance  or
school  blanket  coverage  for  inpatient  hospital care] MEDICAL, MAJOR
MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE must  provide  OUTPATIENT
coverage for [at least sixty outpatient visits in any calendar year for]
the diagnosis and treatment of [chemical dependence of which up to twen-
ty may be for family members, except that this provision shall not apply
to  a  contract  issued  pursuant to section four thousand three hundred
five of this article which covers persons  employed  in  more  than  one
state  or  the  benefit structure of which was the subject of collective
bargaining affecting persons who are employed in more than  one  state.]
SUBSTANCE  USE  DISORDER,  INCLUDING  DETOXIFICATION  AND REHABILITATION
SERVICES.   SUCH COVERAGE SHALL  NOT  APPLY  FINANCIAL  REQUIREMENTS  OR
TREATMENT LIMITATIONS TO OUTPATIENT SUBSTANCE USE DISORDER BENEFITS THAT
ARE  MORE  RESTRICTIVE  THAN  THE PREDOMINANT FINANCIAL REQUIREMENTS AND
TREATMENT LIMITATIONS APPLIED TO SUBSTANTIALLY ALL MEDICAL AND  SURGICAL
BENEFITS  COVERED  BY  THE  CONTRACT.    FURTHER, SUCH COVERAGE SHALL BE
PROVIDED CONSISTENT WITH THE FEDERAL PAUL WELLSTONE  AND  PETE  DOMENICI
MENTAL  HEALTH  PARITY  AND  ADDICTION  EQUITY  ACT OF 2008 (29 U.S.C. S
1185A).
  [Such coverage] (2) COVERAGE UNDER THIS SUBSECTION may be  limited  to
facilities  in  New York state certified by the office of alcoholism and
substance abuse services or licensed by such office as outpatient  clin-

S. 7912                             6                           A. 10164

ics  or medically supervised ambulatory substance abuse programs and, in
other states, to those which are accredited by the joint commission  [on
accreditation   of  hospitals]  as  alcoholism  or  chemical  dependence
substance abuse treatment programs.
  [Such  coverage]  (3)  COVERAGE  PROVIDED UNDER THIS SUBSECTION may be
subject to annual deductibles and co-insurance as [may be] deemed appro-
priate by the superintendent and THAT are consistent with those  imposed
on  other  benefits  within  a given [policy] CONTRACT.   [Such coverage
shall not replace, restrict or eliminate existing coverage  provided  by
the  policy.  Except  as  otherwise provided in the applicable policy or
contract, no hospital service corporation or health service  corporation
providing  coverage  for alcoholism or substance abuse services pursuant
to this section shall deny coverage to a family member]
  (4) A CONTRACT PROVIDING COVERAGE FOR SUBSTANCE USE DISORDER  SERVICES
PURSUANT TO THIS SUBSECTION SHALL PROVIDE UP TO TWENTY OUTPATIENT VISITS
PER CONTRACT OR CALENDAR YEAR TO AN INDIVIDUAL who identifies [themself]
HIM  OR  HERSELF  as  a  family  member  of a person suffering from [the
disease of alcoholism, substance abuse or chemical dependency] SUBSTANCE
USE DISORDER and who seeks treatment as a family member who is otherwise
covered  by  the  applicable  [policy  or]  contract  pursuant  to  this
[section]  SUBSECTION.    The coverage required by this subsection shall
include treatment as a family member pursuant to such family  [members']
MEMBER'S own [policy or] contract provided such family member:
  [(i)]  (A)  does  not  exceed  the  allowable  number of family visits
provided by  the  applicable  [policy  or]  contract  pursuant  to  this
[section,] SUBSECTION; and
  [(ii)]  (B)  is  otherwise  entitled  to  coverage  pursuant  to  this
[section] SUBSECTION and  such  family  [members']  MEMBER'S  applicable
[policy or] contract.
  S  3-a. Item (ii) of subparagraph (B) of paragraph 1 of subsection (b)
of section 4900 of the insurance law, as amended by chapter 586  of  the
laws  of 1998, is amended and a new subparagraph (C) is added to read as
follows:
  (ii) is in the same profession and same or similar  specialty  as  the
health  care  provider  who  typically  manages the medical condition or
disease or provides the health care service or treatment  under  review;
[and] OR
  (C)  FOR  PURPOSES OF A DETERMINATION INVOLVING SUBSTANCE USE DISORDER
TREATMENT:
  (I) A PHYSICIAN WHO  POSSESSES  A  CURRENT  AND  VALID  NON-RESTRICTED
LICENSE  TO  PRACTICE  MEDICINE AND WHO SPECIALIZES IN BEHAVIORAL HEALTH
AND HAS EXPERIENCE IN THE DELIVERY OF SUBSTANCE USE DISORDER COURSES  OF
TREATMENT; OR
  (II)  A  HEALTH  CARE PROFESSIONAL OTHER THAN A LICENSED PHYSICIAN WHO
SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE IN THE  DELIVERY  OF
SUBSTANCE  USE  DISORDER  COURSES  OF  TREATMENT  AND, WHERE APPLICABLE,
POSSESSES A CURRENT AND VALID  NON-RESTRICTED  LICENSE,  CERTIFICATE  OR
REGISTRATION OR, WHERE NO PROVISION FOR A LICENSE, CERTIFICATE OR REGIS-
TRATION  EXISTS, IS CREDENTIALED BY THE NATIONAL ACCREDITING BODY APPRO-
PRIATE TO THE PROFESSION; AND
  S 4. Subsection (a) of section 4902 of the insurance law is amended by
adding a new paragraph 9 to read as follows:
  (9) WHEN CONDUCTING UTILIZATION REVIEW  FOR  PURPOSES  OF  DETERMINING
HEALTH CARE COVERAGE FOR SUBSTANCE USE DISORDER TREATMENT, A UTILIZATION
REVIEW  AGENT  SHALL UTILIZE RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED
CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE AGE OF  THE  PATIENT

S. 7912                             7                           A. 10164

AND  IS 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.
  THE  OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION
WITH THE COMMISSIONER OF HEALTH AND THE SUPERINTENDENT SHALL  APPROVE  A
RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA, IN
ADDITION TO ANY OTHER APPROVED EVIDENCE-BASED AND PEER REVIEWED CLINICAL
REVIEW CRITERIA.
  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) (1) A utilization review agent shall make a determination  involv-
ing  continued or extended health care services, additional services for
an insured undergoing a course of continued treatment  prescribed  by  a
health  care  provider, OR REQUESTS FOR INPATIENT SUBSTANCE USE DISORDER
TREATMENT, or home health care services following an inpatient  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 writing  within  one
business  day  of  receipt  of  the  necessary  information except, with
respect to home health care services  following  an  inpatient  hospital
admission, within seventy-two hours of receipt of the necessary informa-
tion  when the day subsequent to the request falls on a weekend or holi-
day AND EXCEPT, WITH RESPECT TO INPATIENT SUBSTANCE USE DISORDER  TREAT-
MENT,  WITHIN  TWENTY-FOUR  HOURS OF RECEIPT OF THE REQUEST FOR SERVICES
WHEN THE REQUEST IS  SUBMITTED  AT  LEAST  TWENTY-FOUR  HOURS  PRIOR  TO
DISCHARGE  FROM  AN  INPATIENT ADMISSION.   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.
  (2) 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 determination  by  the  utilization  review
agent is pending.
  (3)  PROVIDED THAT A REQUEST FOR INPATIENT TREATMENT FOR SUBSTANCE USE
DISORDER  IS  SUBMITTED  TO  THE  UTILIZATION  REVIEW  AGENT  AT   LEAST
TWENTY-FOUR  HOURS PRIOR TO DISCHARGE FROM AN INPATIENT ADMISSION PURSU-
ANT TO THIS SUBSECTION, A UTILIZATION REVIEW AGENT SHALL  NOT  DENY,  ON
THE  BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE
FOR THE INPATIENT SUBSTANCE USE DISORDER 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

S. 7912                             8                           A. 10164

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 EXCEPT,
WITH RESPECT TO INPATIENT  SUBSTANCE  USE  DISORDER  TREATMENT  PROVIDED
PURSUANT  TO  PARAGRAPH THREE OF SUBSECTION (C) OF SECTION FOUR THOUSAND
NINE HUNDRED THREE OF THIS ARTICLE, EXPEDITED APPEALS  SHALL  BE  DETER-
MINED  WITHIN  TWENTY-FOUR  HOURS  OF RECEIPT OF SUCH APPEAL.  Expedited
appeals which do not result in a resolution satisfactory to the  appeal-
ing  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 FILES AN EXPEDITED INTER-
NAL AND EXTERNAL APPEAL WITHIN TWENTY-FOUR  HOURS  FROM  RECEIPT  OF  AN
ADVERSE DETERMINATION FOR INPATIENT SUBSTANCE USE DISORDER TREATMENT FOR
WHICH  COVERAGE WAS PROVIDED WHILE THE INITIAL UTILIZATION REVIEW DETER-
MINATION WAS PENDING PURSUANT TO PARAGRAPH THREE OF  SUBSECTION  (C)  OF
SECTION  FOUR THOUSAND NINE HUNDRED THREE OF THIS ARTICLE, A UTILIZATION
REVIEW AGENT SHALL NOT DENY ON THE BASIS OF MEDICAL NECESSITY OR LACK OF
PRIOR AUTHORIZATION SUCH SUBSTANCE USE DISORDER TREATMENT WHILE A DETER-
MINATION BY THE UTILIZATION REVIEW AGENT OR  EXTERNAL  APPEAL  AGENT  IS
PENDING.
  S  6-a. Item (B) of subparagraph (i) of paragraph (a) of subdivision 2
of section 4900 of the public health law, as amended by chapter  586  of
the  laws  of  1998, is amended and a new subparagraph (iii) is added to
read as follows:
  (B) is in the same profession and same or  similar  specialty  as  the
health  care  provider  who  typically  manages the medical condition or
disease or provides the health care service or treatment  under  review;
[and] OR
  (III) FOR PURPOSES OF A DETERMINATION INVOLVING SUBSTANCE USE DISORDER
TREATMENT:
  (A)  A  PHYSICIAN  WHO  POSSESSES  A  CURRENT AND VALID NON-RESTRICTED
LICENSE TO PRACTICE MEDICINE AND WHO SPECIALIZES  IN  BEHAVIORAL  HEALTH
AND  HAS EXPERIENCE IN THE DELIVERY OF SUBSTANCE USE DISORDER COURSES OF
TREATMENT; OR
  (B) A HEALTH CARE PROFESSIONAL OTHER THAN  A  LICENSED  PHYSICIAN  WHO
SPECIALIZES  IN  BEHAVIORAL HEALTH AND HAS EXPERIENCE IN THE DELIVERY OF
SUBSTANCE USE DISORDER  COURSES  OF  TREATMENT  AND,  WHERE  APPLICABLE,
POSSESSES  A  CURRENT  AND  VALID NON-RESTRICTED LICENSE, CERTIFICATE OR
REGISTRATION OR, WHERE NO PROVISION FOR A LICENSE, CERTIFICATE OR REGIS-
TRATION EXISTS, IS CREDENTIALED BY THE NATIONAL ACCREDITING BODY  APPRO-
PRIATE TO THE PROFESSION; AND
  S 7. Subdivision 1 of section 4902 of the public health law is amended
by adding a new paragraph (i) to read as follows:
  (I)  WHEN  CONDUCTING  UTILIZATION  REVIEW FOR PURPOSES OF DETERMINING
HEALTH CARE COVERAGE FOR SUBSTANCE USE DISORDER TREATMENT, A UTILIZATION
REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED AND  PEER  REVIEWED
CLINICAL  REVIEW  CRITERIA THAT IS APPROPRIATE TO THE AGE OF THE PATIENT
AND IS 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 FINANCIAL SERVICES.
  THE  OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION
WITH THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL SERVICES SHALL

S. 7912                             9                           A. 10164

APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER  REVIEWED  CLINICAL  REVIEW
CRITERIA,  IN  ADDITION  TO  ANY  OTHER APPROVED EVIDENCE-BASED AND PEER
REVIEWED CLINICAL REVIEW CRITERIA.
  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) 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 REQUESTS FOR INPATIENT SUBSTANCE USE DISORDER
TREATMENT, or home health care services following an inpatient  hospital
admission,  and shall provide notice of such determination to the enrol-
lee or the enrollee's designee, which may be satisfied by notice to  the
enrollee's  health care provider, by telephone and in writing within one
business day of  receipt  of  the  necessary  information  except,  with
respect  to  home  health  care services following an inpatient hospital
admission, within seventy-two hours of receipt of the necessary informa-
tion when the day subsequent to the request falls on a weekend or  holi-
day  AND EXCEPT, WITH RESPECT TO INPATIENT SUBSTANCE USE DISORDER TREAT-
MENT, WITHIN TWENTY-FOUR HOURS OF RECEIPT OF THE  REQUEST  FOR  SERVICES
WHEN  THE  REQUEST  IS  SUBMITTED  AT  LEAST  TWENTY-FOUR HOURS PRIOR TO
DISCHARGE FROM AN INPATIENT  ADMISSION.  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.
  (B)  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.
  (C) PROVIDED THAT A REQUEST FOR INPATIENT TREATMENT FOR SUBSTANCE  USE
DISORDER   IS  SUBMITTED  TO  THE  UTILIZATION  REVIEW  AGENT  AT  LEAST
TWENTY-FOUR HOURS PRIOR TO DISCHARGE FROM AN INPATIENT ADMISSION  PURSU-
ANT  TO  THIS SUBDIVISION, A UTILIZATION REVIEW AGENT SHALL NOT DENY, ON
THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION,  COVERAGE
FOR THE INPATIENT SUBSTANCE USE DISORDER TREATMENT 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
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

S. 7912                            10                           A. 10164

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 EXCEPT,
WITH RESPECT TO INPATIENT  SUBSTANCE  USE  DISORDER  TREATMENT  PROVIDED
PURSUANT TO PARAGRAPH (C) OF SUBDIVISION 3 OF SECTION FOUR THOUSAND NINE
HUNDRED  THREE  OF  THIS  ARTICLE, EXPEDITED APPEALS SHALL BE DETERMINED
WITHIN TWENTY-FOUR HOURS OF RECEIPT OF SUCH  APPEAL.  Expedited  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 four-
teen  of  this article as applicable.  PROVIDED THAT THE ENROLLEE OR THE
ENROLLEE'S HEALTH CARE PROVIDER FILES AN EXPEDITED INTERNAL AND EXTERNAL
APPEAL WITHIN TWENTY-FOUR HOURS FROM RECEIPT OF AN ADVERSE DETERMINATION
FOR INPATIENT SUBSTANCE USE DISORDER TREATMENT FOR  WHICH  COVERAGE  WAS
PROVIDED  WHILE THE INITIAL UTILIZATION REVIEW DETERMINATION WAS PENDING
PURSUANT TO PARAGRAPH (C) OF SUBDIVISION 3 OF SECTION FOUR THOUSAND NINE
HUNDRED THREE OF THIS ARTICLE, A UTILIZATION REVIEW AGENT SHALL NOT DENY
ON THE BASIS OF MEDICAL NECESSITY OR LACK OF  PRIOR  AUTHORIZATION  SUCH
SUBSTANCE  USE  DISORDER TREATMENT WHILE A DETERMINATION BY THE UTILIZA-
TION REVIEW AGENT OR EXTERNAL APPEAL AGENT IS PENDING.
  S 10. Section 309 of the insurance law is  amended  by  adding  a  new
subsection (c) to read as follows:
  (C)  AS PART OF AN EXAMINATION, THE SUPERINTENDENT SHALL REVIEW DETER-
MINATIONS OF COVERAGE FOR SUBSTANCE USE  DISORDER  TREATMENT  AND  SHALL
ENSURE  THAT  SUCH DETERMINATIONS ARE ISSUED IN COMPLIANCE WITH SECTIONS
THREE  THOUSAND  TWO  HUNDRED  SIXTEEN,  THREE  THOUSAND   TWO   HUNDRED
TWENTY-ONE,  FOUR THOUSAND THREE HUNDRED THREE, AND TITLE ONE OF ARTICLE
FORTY-NINE OF THIS CHAPTER.
  S 10-a. Subdivision 2 of section 4409 of the  public  health  law,  as
amended  by  chapter  805  of  the  laws  of 1984, is amended to read as
follows:
  2. The superintendent shall examine not less  than  once  every  three
years  into  the  financial affairs of each health maintenance organiza-
tion, and transmit his findings to the commissioner. In connection  with
any such examination, the superintendent shall have convenient access at
all  reasonable  hours  to all books, records, files and other documents
relating to the affairs of such organization, which are relevant to  the
examination.  The  superintendent  may  exercise the powers set forth in
sections three hundred four, three hundred five, three hundred  six  and
three  hundred ten of the insurance law in connection with such examina-
tions, and may also require special reports from such health maintenance
organizations as specified in section three hundred eight of the  insur-
ance  law.    AS PART OF AN EXAMINATION, THE SUPERINTENDENT SHALL REVIEW
DETERMINATIONS OF COVERAGE FOR  SUBSTANCE  USE  DISORDER  TREATMENT  AND
SHALL  ENSURE  THAT  SUCH  DETERMINATIONS  ARE ISSUED IN COMPLIANCE WITH
SECTION FOUR THOUSAND THREE HUNDRED THREE OF THE INSURANCE LAW AND TITLE
ONE OF ARTICLE FORTY-NINE OF THIS CHAPTER.
  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 use
disorder 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  provid-

S. 7912                            11                           A. 10164

ers,  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 use disorder
treatment services for across the state;
  b. Recommendations  for  increasing  access  to  and  availability  of
substance use disorder treatment services in the state, including under-
served areas of the state;
  c.  Identifying  best  clinical  practices  for substance use disorder
treatment services;
  d. A review of current insurance coverage requirements and recommenda-
tions for improving insurance coverage for substance use disorder treat-
ment;
  e.  Recommendations  for  improving  state  agency  communication  and
collaboration  relating  to substance use disorder treatment services in
the state;
  f. Resources for affected individuals  and  families  who  are  having
difficulties   obtaining  necessary  substance  use  disorder  treatment
services; and
  g. Methods for developing quality standards to measure the performance
of substance use disorder 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; provided,  however  that
sections  one, two, three, three-a, four, five, six, six-a, seven, eight
and nine of this act shall take effect April 1, 2015 and shall apply  to
policies  and contracts issued, renewed, modified, altered or amended on
and after such date.