S T A T E O F N E W Y O R K
________________________________________________________________________
3694--B
2017-2018 Regular Sessions
I N A S S E M B L Y
January 30, 2017
___________
Introduced by M. of A. GUNTHER -- read once and referred to the Commit-
tee on Insurance -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee -- recommitted
to the Committee on Insurance in accordance with Assembly Rule 3, sec.
2 -- committee discharged, bill amended, ordered reprinted as amended
and recommitted to said committee
AN ACT to amend the insurance law, in relation to establishing the
mental health and substance use disorder parity report act
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Short title. This act shall be known and may be cited as
the "mental health and substance use disorder parity report act".
§ 2. Subsection (a) of section 210 of the insurance law, as amended by
chapter 579 of the laws of 1998, is amended to read as follows:
(a) The superintendent shall annually publish on or before September
first, nineteen hundred ninety-nine, and annually thereafter, a consumer
guide to insurers providing managed care products, individual accident
and health insurance or group or blanket accident and health insurance
and entities licensed pursuant to article forty-four of the public
health law providing comprehensive health service plans which includes,
in detail, a ranking from best to worst based upon each company's claim
processing or medical payments record during the preceding calendar year
using criteria available to the department, adjusted for volume of
coverage provided. Such ranking shall also take into consideration the
corresponding total number or percentage of claims denied which were
reversed or compromised after intervention by the department and the
department of health, consumer complaints to the department and the
department of health, violations of section three thousand two hundred
twenty-four-a of this chapter and other pertinent data which would
permit the department to objectively determine a company's performance.
The department in publishing such consumer guide shall publish one
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02509-10-8
A. 3694--B 2
state-wide guide or no more than five regional guides so as to facili-
tate comparisons among individual insurers and entities within a service
market area. Such rankings shall be printed in a format which ranks all
health insurers and all entities certified pursuant to article forty-
four of the public health law in one combined list. THE CONSUMER GUIDE
ON OR BEFORE SEPTEMBER FIRST, TWO THOUSAND NINETEEN AND ANNUALLY THERE-
AFTER, SHALL INCLUDE A MENTAL HEALTH PARITY REPORT AND A SUBSTANCE USES
DISORDER PARITY REPORT BASED UPON EACH COMPANY'S COMPLIANCE WITH MENTAL
HEALTH PARITY AND SUBSTANCE USE DISORDER PARITY LAWS BASED ON EACH
COMPANY'S RECORD DURING THE PRECEDING CALENDAR YEAR USING CRITERIA
AVAILABLE TO THE DEPARTMENT, INCLUDING, BUT NOT LIMITED TO, INFORMATION
REQUIRED BY THIS SUBSECTION AND SUBSECTIONS (B), (C) AND (D) OF THIS
SECTION. IN ADDITION, NOTWITHSTANDING SUCH REQUIREMENTS AND ANY LAW TO
THE CONTRARY, THE DATA TO BE INCLUDED IN THE MENTAL HEALTH PARITY REPORT
AND THE SUBSTANCE USE DISORDER PARITY REPORT AND COLLECTED BY THE SUPER-
INTENDENT AND THE COMMISSIONER OF HEALTH FROM INSURERS AND HEALTH PLANS,
FOR SUCH PURPOSES SHALL INCLUDE:
(1) ANNUAL MENTAL HEALTH PARITY AND SUBSTANCE USE DISORDER PARITY
COMPLIANCE REPORTS FROM EACH INSURER AND HEALTH PLAN OUTLINING HOW IT
COMPLIES WITH TIMOTHY'S LAW, THE INSURANCE LAW PROVISIONS REGARDING
SUBSTANCE USE DISORDER AND EATING DISORDERS AND THE PAUL WELLSTONE AND
PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF TWO THOU-
SAND EIGHT;
(2) RATES OF UTILIZATION REVIEW FOR MENTAL HEALTH AND SUBSTANCE USE
DISORDER CLAIMS AS COMPARED TO MEDICAL AND SURGICAL CLAIMS, INCLUDING
RATES OF APPROVAL AND DENIAL, CATEGORIZED BY BENEFITS PROVIDED UNDER THE
FOLLOWING CLASSIFICATIONS, AS REQUIRED UNDER 45 C.F.R. § 146.136, 29
C.F.R. § 2590.712 AND 26 C.F.R. § 54.9812-1.: INPATIENT IN-NETWORK,
INPATIENT OUT-OF-NETWORK, OUTPATIENT IN-NETWORK, OUTPATIENT OUT-OF-NET-
WORK, EMERGENCY CARE, AND PRESCRIPTION DRUGS;
(3) THE NUMBER OF PRIOR OR CONCURRENT AUTHORIZATION REQUESTS FOR
MENTAL HEALTH SERVICES AND FOR SUBSTANCE USE DISORDER SERVICES AND THE
NUMBER OF DENIALS FOR SUCH REQUESTS, COMPARED WITH THE NUMBER OF PRIOR
OR CONCURRENT AUTHORIZATION REQUESTS FOR MEDICAL AND SURGICAL SERVICES
AND THE NUMBER OF DENIALS FOR SUCH REQUESTS, CATEGORIZED BY THE SAME
CLASSIFICATIONS IDENTIFIED IN PARAGRAPH TWO OF THIS SUBSECTION WHICH
SHALL ALSO INCLUDE THE RATES OF INTERNAL AND EXTERNAL APPEALS, INCLUDING
RATES OF APPEALS UPHELD AND OVERTURNED, SPECIFICALLY FOR MENTAL HEALTH
BENEFITS AND SUBSTANCE USE DISORDER BENEFITS;
(4) THE NUMBER OF PRIOR OR CONCURRENT AUTHORIZATION REQUESTS FOR
MENTAL HEALTH SERVICES AND SUBSTANCE USE DISORDER SERVICES THAT WENT TO
CLINICAL PEER REVIEW AS A RESULT OF A DISAGREEMENT BETWEEN THE SERVICE
PROVIDER AND THE INSURER OR HEALTH PLAN AND THE NUMBER THAT WENT TO
CLINICAL PEER REVIEW FOR MEDICAL AND SURGICAL SERVICES CATEGORIZED IN
THE SAME MANNER AS PROVIDED IN PARAGRAPH TWO OF THIS SUBSECTION;
(5) THE LIST OF SERVICES THAT HAVE A PRIOR OR CONCURRENT AUTHORIZATION
REQUIREMENT BASED ON A NUMERICAL THRESHOLD DEFINED BY A SPECIFIC NUMBER
OF VISITS OR DAYS OF CARE FOR MENTAL HEALTH SERVICES, SUBSTANCE USE
DISORDER SERVICES AND MEDICAL AND SURGICAL SERVICES AND IDENTIFICATION
OF THE THRESHOLD REQUIREMENTS;
(6) THE LIST OF COVERED MEDICATIONS FOR THE TREATMENT OF A SUBSTANCE
USE DISORDER ON THE PRESCRIPTION DRUG LIST OF THE INSURER OR HEALTH PLAN
INCLUDING TIER PLACEMENT, AUTHORIZATION REQUIREMENTS AND ALL OTHER
UTILIZATION MANAGEMENT REQUIREMENTS;
A. 3694--B 3
(7) THE PERCENTAGE OF CLAIMS PAID FOR IN-NETWORK MENTAL HEALTH
SERVICES AND FOR SUBSTANCE USE DISORDER SERVICES AND THE PERCENTAGE OF
CLAIMS PAID FOR IN-NETWORK MEDICAL AND SURGICAL SERVICES;
(8) THE PERCENTAGE OF CLAIMS PAID FOR OUT-OF-NETWORK MENTAL HEALTH
SERVICES AND SUBSTANCE USE DISORDER SERVICES COMPARED WITH THE PERCENT-
AGE OF CLAIMS PAID FOR OTHER TYPES OF OUT-OF-NETWORK MEDICAL AND SURGI-
CAL SERVICES;
(9) THE MEDICAL NECESSITY CRITERIA THE INSURER OR HEALTH PLAN USES TO
MAKE PRIOR AUTHORIZATION OR CONTINUING CARE AND DISCHARGE DETERMI-
NATIONS, WHICH IN CONJUNCTION MUST BE CONSPICUOUSLY POSTED FOR POLICY-
HOLDERS AND PROVIDERS TO BE ABLE TO REVIEW WITHOUT MAKING A REQUEST ON
THE INSURER'S OR THE HEALTH PLAN'S WEBSITE AND BE MADE AVAILABLE IN HARD
COPY UPON REQUEST;
(10) THE NUMBER OF BEHAVIORAL HEALTH ADVOCATES, PURSUANT TO AN AGREE-
MENT WITH THE OFFICE OF THE ATTORNEY GENERAL IF APPLICABLE, OR STAFF ON
HAND TO ASSIST POLICYHOLDERS WITH BENEFITS FOR MENTAL HEALTH OR
SUBSTANCE USE DISORDER;
(11) THE NETWORK ADEQUACY OF INSURERS AND HEALTH PLANS, WHICH IN ADDI-
TION TO THE REQUIREMENTS OF SUBSECTION (A) OF SECTION THREE THOUSAND TWO
HUNDRED FORTY-ONE OF THIS CHAPTER AND SUBSECTION (C) OF THIS SECTION,
SHALL CONSIST OF VERIFYING THE MENTAL HEALTH AND SUBSTANCE USE DISORDER
PROVIDERS LISTED IN AN INSURER'S OR HEALTH PLAN'S PROVIDER DIRECTORY AS
IN NETWORK. SUCH VERIFICATION SHALL BE PROVIDED BY THE INSURER OR HEALTH
PLAN, ON A SEMI-ANNUAL BASIS, BY PROVIDING ITS LIST OF IN-NETWORK MENTAL
HEALTH AND SUBSTANCE USE DISORDER PROVIDERS AND THE NUMBER OF CLAIMS
EACH PROVIDER HAS SUBMITTED WITHIN THE PAST SIX MONTHS. THE LIST SHALL
INCLUDE THE NAME, ADDRESS AND TELEPHONE NUMBER OF ALL PARTICIPATING
IN-NETWORK PROVIDERS. FOR PROVIDERS THAT HAVE HAD NO CLAIMS IN THE PAST
SIX MONTHS, THE INSURER OR HEALTH PLAN MUST PROVIDE AN ATTESTATION THAT
SUCH PROVIDER IS STILL PART OF THE NETWORK AND THAT THE PROVIDER IS
ACCEPTING NEW PATIENTS. FOR QUALIFIED HEALTH PLANS OFFERED ON NEW YORK
STATE OF HEALTH, THE DEPARTMENT OF HEALTH SHALL REVIEW THE NETWORK
ADEQUACY TO ENSURE IT IS CONSISTENT WITH 45 CFR § 156.230 AND THE
DEPARTMENT OF HEALTH'S MANAGED CARE NETWORK ADEQUACY STANDARD INCLUDING
VERIFICATION OF THE MENTAL HEALTH AND SUBSTANCE USE DISORDER PROVIDERS
LISTED IN A QUALIFIED HEALTH PLAN'S PROVIDER DIRECTORY AS IN-NETWORK.
SUCH VERIFICATION SHALL BE PROVIDED BY A QUALIFIED HEALTH PLAN, ON A
SEMI-ANNUAL BASIS, BY PROVIDING ITS LIST OF IN-NETWORK MENTAL HEALTH AND
SUBSTANCE USE DISORDER PROVIDERS AND THE NUMBER OF CLAIMS EACH PROVIDER
HAS SUBMITTED WITHIN THE PAST SIX MONTHS. THE LIST SHALL INCLUDE THE
NAME, ADDRESS AND TELEPHONE NUMBER OF ALL PARTICIPATING PROVIDERS. FOR
PROVIDERS THAT HAVE NO CLAIMS IN THE PAST SIX MONTHS, THE QUALIFIED
HEALTH PLAN MUST PROVIDE AN ATTESTATION THAT SUCH PROVIDER IS STILL PART
OF THE NETWORK AND THAT THE PROVIDER IS ACCEPTING NEW PATIENTS;
(12) THE NUMBER OF MENTAL HEALTH AND SUBSTANCE USE DISORDER PROVIDERS
WHO HAVE LEFT OR BEEN REMOVED FROM THE PROVIDER NETWORK IN THE PAST SIX
MONTHS AND THE REASON THAT THEY HAVE LEFT OR BEEN REMOVED; AND
(13) ANY OTHER DATA OR METRIC THE SUPERINTENDENT OR THE COMMISSIONER
OF HEALTH DEEMS IS NECESSARY TO MEASURE COMPLIANCE WITH MENTAL HEALTH
PARITY AND SUBSTANCE USE DISORDER PARITY.
§ 3. Paragraph 2 of subsection (c) of section 210 of the insurance
law, as added by chapter 579 of the laws of 1998, is amended to read as
follows:
(2) the percentage of primary care physicians who remained participat-
ing providers, provided however, that such percentage shall exclude
voluntary terminations due to physician retirement, relocation or other
A. 3694--B 4
similar reasons, AND THE PERCENTAGE OF MENTAL HEALTH PROFESSIONALS,
DEFINED AS PHYSICIANS WHO ARE LICENSED PURSUANT TO ARTICLE ONE HUNDRED
THIRTY-ONE OF THE EDUCATION LAW WHO ARE DIPLOMATS OF THE AMERICAN BOARD
OF PSYCHIATRY AND NEUROLOGY OR ARE ELIGIBLE TO BE CERTIFIED BY THAT
BOARD, OR ARE CERTIFIED BY THE AMERICAN OSTEOPATHIC BOARD OF NEUROLOGY
AND PSYCHIATRY OR ARE ELIGIBLE TO BE CERTIFIED BY THAT BOARD, A SOCIAL
WORKER LICENSED PURSUANT TO ARTICLE ONE HUNDRED FIFTY-FOUR OF THE EDUCA-
TION LAW OR A PSYCHOLOGIST LICENSED PURSUANT TO ARTICLE ONE HUNDRED
FIFTY-THREE OF THE EDUCATION LAW, WHO REMAINED AS PARTICIPATING PROVID-
ERS AND THE NUMBER OF CLAIMS EACH TYPE OF MENTAL HEALTH PROFESSIONAL HAS
SUBMITTED IN THE LAST TWELVE MONTHS AND THE NUMBER OF MENTAL HEALTH
PROFESSIONALS, IF ANY, WHO HAVE NOT HAD ANY CLAIMS IN THE LAST TWELVE
MONTHS;
§ 4. Subsection (d) of section 210 of the insurance law, as added by
chapter 579 of the laws of 1998, is amended to read as follows:
(d) Health insurers and entities certified pursuant to article forty-
four of the public health law shall provide annually to the superinten-
dent and the commissioner of health, and the commissioner of health
shall provide to the superintendent, all of the information necessary
for the superintendent to produce the annual consumer guide, INCLUDING
THE MENTAL HEALTH PARITY REPORT AND THE SUBSTANCE USE DISORDER PARITY
REPORT. In compiling the guide, the superintendent shall make every
effort to ensure that the information is presented in a clear, under-
standable fashion which facilitates comparisons among individual insur-
ers and entities, and in a format which lends itself to the widest
possible distribution to consumers. The superintendent shall either
include the information from the annual consumer guide in the consumer
shopping guide required by subsection (a) of section four thousand three
hundred twenty-three of this chapter or combine the two guides as long
as consumers in the individual market are provided with the information
required by subsection (a) of section four thousand three hundred twen-
ty-three of this chapter.
§ 5. This act shall take effect on the sixtieth day after it shall
have become a law, provided, however, effective immediately, the amend-
ment and/or repeal of any rule or regulation necessary for the implemen-
tation of this act on its effective date are authorized and directed to
be made and completed on or before such effective date.