S T A T E O F N E W Y O R K
________________________________________________________________________
7522
2023-2024 Regular Sessions
I N A S S E M B L Y
May 25, 2023
___________
Introduced by M. of A. GUNTHER -- read once and referred to the Commit-
tee on Insurance
AN ACT to amend the insurance law, in relation to prohibiting the appli-
cation of fail-first or step therapy protocols to coverage for the
diagnosis and treatment of serious mental health conditions
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Item (ii) of subparagraph (A) and subparagraphs (C) and (E)
of paragraph 35 of subsection (i) of section 3216 of the insurance law,
item (ii) of subparagraph (A) as amended by chapter 62 of the laws of
2023 and subparagraphs (C) and (E) as added by section 8 of subpart A of
part BB of chapter 57 of the laws of 2019, are amended to read as
follows:
(ii) where the policy provides coverage for physician services, such
policy shall include benefits for outpatient care provided by a psychia-
trist or psychologist licensed to practice in this state, a licensed
clinical social worker within the lawful scope of his or her practice,
who is licensed pursuant to article one hundred fifty-four of the educa-
tion law, a mental health counselor, marriage and family therapist, or
psychoanalyst licensed pursuant to article one hundred sixty-three of
the education law, a nurse practitioner licensed to practice in this
state, or a professional corporation or university faculty practice
corporation thereof, INCLUDING OUTPATIENT DRUG COVERAGE. Nothing herein
shall be construed to modify or expand the scope of practice of a mental
health counselor, marriage and family therapist, or psychoanalyst
licensed pursuant to article one hundred sixty-three of the education
law. Further, nothing herein shall be construed to create a new mandated
health benefit.
(C) Coverage under this paragraph shall not apply financial require-
ments or treatment limitations to mental health benefits, INCLUDING
OUTPATIENT DRUG COVERAGE, that are more restrictive than the predominant
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD11141-05-3
A. 7522 2
financial requirements and treatment limitations applied to substantial-
ly all medical and surgical benefits covered by the policy. COVERAGE
UNDER THIS PARAGRAPH, INCLUDING DRUG COVERAGE, SHALL NOT APPLY ANY OF
THE FOLLOWING TO A DRUG OR DRUGS PRESCRIBED FOR A SERIOUS MENTAL HEALTH
CONDITION:
(I) A FAIL-FIRST OR STEP THERAPY PROTOCOL, AS DEFINED BY SECTION FOUR
THOUSAND NINE HUNDRED OF THIS CHAPTER; OR
(II) A PRIOR AUTHORIZATION REQUIREMENT, AS ESTABLISHED PURSUANT TO
SUBSECTION (H) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS CHAP-
TER.
(E) For purposes of this paragraph:
(i) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;
(iii) "treatment limitation" means limits on the frequency of treat-
ment, number of visits, days of coverage, or other similar limits on the
scope or duration of treatment and includes nonquantitative treatment
limitations such as: medical management standards limiting or excluding
benefits based on medical necessity, or based on whether the treatment
is experimental or investigational; formulary design for prescription
drugs; network tier design; standards for provider admission to partic-
ipate in a network, including reimbursement rates; methods for determin-
ing usual, customary, and reasonable charges; fail-first or step therapy
protocols; exclusions based on failure to complete a course of treat-
ment; and restrictions based on geographic location, facility type,
provider specialty, and other criteria that limit the scope or duration
of benefits for services provided under the policy; [and]
(iv) "mental health condition" means any mental health disorder as
defined in the most recent edition of the diagnostic and statistical
manual of mental disorders or the most recent edition of another gener-
ally recognized independent standard of current medical practice such as
the international classification of diseases[.]; AND
(V) "SERIOUS MENTAL HEALTH CONDITION" MEANS THE FOLLOWING MENTAL
HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS:
(I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
(II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
(III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
(IV) OBSESSIVE-COMPULSIVE DISORDERS;
(V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
(VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
(VII) SCHIZOPHRENIA.
§ 1-a. Items (vi) and (vii) of subparagraph (E) of paragraph 35 of
subsection (i) of section 3216 of the insurance law, as added by section
2 of subpart A of part II of chapter 57 of the laws of 2023, are amend
and a new item (viii) is added to read as follows:
(vi) "critical time intervention services" means services rendered by
a provider licensed under article thirty-one of the mental hygiene law
that provides evidence-based, therapeutic interventions that include
intensive outreach, engagement, and care coordination services that are
provided to an insured before the insured is discharged from inpatient
care in a hospital as defined by subdivision ten of section 1.03 of the
mental hygiene law or the emergency department of a hospital licensed
A. 7522 3
pursuant to article twenty-eight of the public health law and continue
after discharge until the insured is stabilized; [and]
(vii) "residential facility" means crisis residence facilities and
community residences for eating disorder integrated treatment programs
licensed pursuant to article thirty-one of the mental hygiene law[.];
AND
(VIII) "SERIOUS MENTAL HEALTH CONDITION" MEANS THE FOLLOWING MENTAL
HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS:
(I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
(II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
(III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
(IV) OBSESSIVE-COMPULSIVE DISORDERS;
(V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
(VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
(VII) SCHIZOPHRENIA.
§ 2. Item (ii) of subparagraph (A) and subparagraphs (C) and (E) of
paragraph 5 of subsection (l) of section 3221 of the insurance law, item
(ii) of subparagraph (A) as amended by chapter 62 of the laws of 2023
and subparagraphs (C) and (E) as added by section 14 of subpart A of
part BB of chapter 57 of the laws of 2019, are amended to read as
follows:
(ii) where the policy provides coverage for physician services, it
shall include benefits for outpatient care provided by a psychiatrist or
psychologist licensed to practice in this state, or a mental health
counselor, marriage and family therapist, or psychoanalyst licensed
pursuant to article one hundred sixty-three of the education law, or a
licensed clinical social worker within the lawful scope of his or her
practice, who is licensed pursuant to article one hundred fifty-four of
the education law, a nurse practitioner licensed to practice in this
state, or a professional corporation or university faculty practice
corporation thereof, INCLUDING OUTPATIENT DRUG COVERAGE. Nothing herein
shall be construed to modify or expand the scope of practice of a mental
health counselor, marriage and family therapist, or psychoanalyst
licensed pursuant to article one hundred sixty-three of the education
law. Further, nothing herein shall be construed to create a new mandated
health benefit.
(C) Coverage under this paragraph shall not apply financial require-
ments or treatment limitations to mental health benefits, INCLUDING
OUTPATIENT DRUG COVERAGE, that are more restrictive than the predominant
financial requirements and treatment limitations applied to substantial-
ly all medical and surgical benefits covered by the policy. COVERAGE
UNDER THIS PARAGRAPH, INCLUDING DRUG COVERAGE, SHALL NOT APPLY ANY OF
THE FOLLOWING TO A DRUG OR DRUGS PRESCRIBED FOR A SERIOUS MENTAL HEALTH
CONDITION:
(I) A FAIL-FIRST OR STEP THERAPY PROTOCOL, AS DEFINED BY SECTION FOUR
THOUSAND NINE HUNDRED OF THIS CHAPTER; OR
(II) A PRIOR AUTHORIZATION REQUIREMENT, AS ESTABLISHED PURSUANT TO
SUBSECTION (H) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS CHAP-
TER.
(E) For purposes of this paragraph:
(i) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;
A. 7522 4
(iii) "treatment limitation" means limits on the frequency of treat-
ment, number of visits, days of coverage, or other similar limits on the
scope or duration of treatment and includes nonquantitative treatment
limitations such as: medical management standards limiting or excluding
benefits based on medical necessity, or based on whether the treatment
is experimental or investigational; formulary design for prescription
drugs; network tier design; standards for provider admission to partic-
ipate in a network, including reimbursement rates; methods for determin-
ing usual, customary, and reasonable charges; fail-first or step therapy
protocols; exclusions based on failure to complete a course of treat-
ment; and restrictions based on geographic location, facility type,
provider specialty, and other criteria that limit the scope or duration
of benefits for services provided under the policy; [and]
(iv) "mental health condition" means any mental health disorder as
defined in the most recent edition of the diagnostic and statistical
manual of mental disorders or the most recent edition of another gener-
ally recognized independent standard of current medical practice such as
the international classification of diseases[.]; AND
(V) "SERIOUS MENTAL HEALTH CONDITION" MEANS THE FOLLOWING MENTAL
HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS:
(I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
(II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
(III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
(IV) OBSESSIVE-COMPULSIVE DISORDERS;
(V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
(VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
(VII) SCHIZOPHRENIA.
§ 2-a. Items (vi) and (vii) of subparagraph (E) of paragraph 5 of
subsection (l) of section 3221 of the insurance law, as added by section
6 of subpart A of part II of chapter 57 of the laws of 2023, are amended
and a new item (viii) is added to read as follows:
(vi) "critical time intervention services" means services rendered by
a provider licensed under article thirty-one of the mental hygiene law
that provides evidence-based, therapeutic interventions that include
intensive outreach, engagement, and care coordination services that are
provided to an insured before the insured is discharged from inpatient
care in a hospital as defined by subdivision ten of section 1.03 of the
mental hygiene law or the emergency department of a hospital licensed
pursuant to article twenty-eight of the public health law and continue
after discharge until the insured is stabilized; [and]
(vii) "residential facility" means crisis residence facilities and
community residences for eating disorder integrated treatment programs
licensed pursuant to article thirty-one of the mental hygiene law[.];
AND
(VIII) "SERIOUS MENTAL HEALTH CONDITION" MEANS THE FOLLOWING MENTAL
HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS:
(I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
(II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
(III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
(IV) OBSESSIVE-COMPULSIVE DISORDERS;
(V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
(VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
(VII) SCHIZOPHRENIA.
A. 7522 5
§ 3. Paragraphs 2, 4, and 6 of subsection (g) of section 4303 of the
insurance law, paragraph 2 as amended by chapter 62 of the laws of 2023,
and paragraphs 4 and 6 as added by section 23 of subpart A of part BB of
chapter 57 of the laws of 2019, are amended to read as follows:
(2) where the contract provides coverage for physician services such
contract shall provide benefits for outpatient care provided by a
psychiatrist or psychologist licensed to practice in this state, or a
mental health counselor, marriage and family therapist, or psychoanalyst
licensed pursuant to article one hundred sixty-three of the education
law, or a licensed clinical social worker within the lawful scope of his
or her practice, who is licensed pursuant to article one hundred fifty-
four of the education law, a nurse practitioner licensed to practice in
this state, or professional corporation or university faculty practice
corporation thereof, INCLUDING OUTPATIENT DRUG COVERAGE. Nothing herein
shall be construed to modify or expand the scope of practice of a mental
health counselor, marriage and family therapist, or psychoanalyst
licensed pursuant to article one hundred sixty-three of the education
law. Further, nothing herein shall be construed to create a new mandated
health benefit.
(4) Coverage under this subsection shall not apply financial require-
ments or treatment limitations to mental health benefits, INCLUDING
OUTPATIENT DRUG COVERAGE, that are more restrictive than the predominant
financial requirements and treatment limitations applied to substantial-
ly all medical and surgical benefits covered by the contract. COVERAGE
UNDER THIS PARAGRAPH, INCLUDING DRUG COVERAGE, SHALL NOT APPLY ANY OF
THE FOLLOWING TO A DRUG OR DRUGS PRESCRIBED FOR A SERIOUS MENTAL HEALTH
CONDITION:
(I) A FAIL-FIRST OR STEP THERAPY PROTOCOL, AS DEFINED BY SECTION FOUR
THOUSAND NINE HUNDRED OF THIS CHAPTER; OR
(II) A PRIOR AUTHORIZATION REQUIREMENT, AS ESTABLISHED PURSUANT TO
SUBSECTION (H) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS CHAP-
TER.
(6) For purposes of this subsection:
(A) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;
(C) "treatment limitation" means limits on the frequency of treatment,
number of visits, days of coverage, or other similar limits on the scope
or duration of treatment and includes nonquantitative treatment limita-
tions such as: medical management standards limiting or excluding bene-
fits based on medical necessity, or based on whether the treatment is
experimental or investigational; formulary design for prescription
drugs; network tier design; standards for provider admission to partic-
ipate in a network, including reimbursement rates; methods for determin-
ing usual, customary, and reasonable charges; fail-first or step therapy
protocols; exclusions based on failure to complete a course of treat-
ment; and restrictions based on geographic location, facility type,
provider specialty, and other criteria that limit the scope or duration
of benefits for services provided under the contract; [and]
(D) "mental health condition" means any mental health disorder as
defined in the most recent edition of the diagnostic and statistical
manual of mental disorders or the most recent edition of another gener-
ally recognized independent standard of current medical practice such as
the international classification of diseases[.]; AND
A. 7522 6
(E) "SERIOUS MENTAL HEALTH CONDITION" MEANS THE FOLLOWING MENTAL
HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS:
(I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
(II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
(III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
(IV) OBSESSIVE-COMPULSIVE DISORDERS;
(V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
(VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
(VII) SCHIZOPHRENIA.
§ 3-a. Subparagraphs (F) and (G) of paragraph 6 of subsection (g) of
section 4303 of the insurance law, as added by section 10 of subpart A
of part II of chapter 57 of the laws of 2023, are amended and a new
subparagraph (H) is added to read as follows:
(F) "critical time intervention services" means services rendered by a
provider licensed under article thirty-one of the mental hygiene law
that provides evidence-based, therapeutic interventions that include
intensive outreach, engagement, and care coordination services that are
provided to an insured before the insured is discharged from inpatient
care in a hospital as defined by subdivision ten of section 1.03 of the
mental hygiene law or the emergency department of a hospital licensed
pursuant to article twenty-eight of the public health law and continue
after discharge until the insured is stabilized; [and]
(G) "residential facility" means crisis residence facilities and
community residences for eating disorder integrated treatment programs
licensed pursuant to article thirty-one of the mental hygiene law[.];
AND
(H) "SERIOUS MENTAL HEALTH CONDITION" MEANS THE FOLLOWING MENTAL
HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS:
(I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
(II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
(III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
(IV) OBSESSIVE-COMPULSIVE DISORDERS;
(V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
(VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
(VII) SCHIZOPHRENIA.
§ 4. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to all
policies and contracts issued, renewed, modified, altered or amended on
or after such date; provided however, that if subpart A of part II of
chapter 57 of the laws of 2023 shall not have taken effect on or before
such date then sections one-a, two-a and three-a of this act shall take
effect on the same date and in the same manner as such subpart of such
part of such chapter of the laws of 2023 takes effect.