S T A T E O F N E W Y O R K
________________________________________________________________________
7288--B
2023-2024 Regular Sessions
I N S E N A T E
May 19, 2023
___________
Introduced by Sens. FERNANDEZ, ADDABBO, RYAN -- read twice and ordered
printed, and when printed to be committed to the Committee on Insur-
ance -- recommitted to the Committee on Insurance in accordance with
Senate Rule 6, sec. 8 -- committee discharged, bill amended, ordered
reprinted as amended and recommitted to said committee -- committee
discharged, bill amended, ordered reprinted as amended and recommitted
to said committee
AN ACT to amend the insurance law, in relation to certain cost sharing
fees for treatment of substance use disorder
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subparagraph (E) of paragraph 31 of subsection (i) of
section 3216 of the insurance law, as amended by section 6 of subpart A
of part BB of chapter 57 of the laws of 2019, is amended and a new
subparagraph (K) is added to read as follows:
(E) This subparagraph shall apply to facilities in this state that are
licensed, certified or otherwise authorized by the office of [alcoholism
and substance abuse] ADDICTION services AND SUPPORTS for the provision
of outpatient, intensive outpatient, outpatient rehabilitation and
opioid treatment that are participating in the insurer's provider
network. Coverage provided under this paragraph shall not be subject to
preauthorization. Coverage provided under this paragraph shall not be
subject to concurrent review for the first four weeks of continuous
treatment, not to exceed twenty-eight visits, provided the facility
notifies the insurer of both the start of treatment and the initial
treatment plan within two business days. The facility shall perform
clinical assessment of the patient at each visit, including periodic
consultation with the insurer at or just prior to the fourteenth day of
treatment to ensure that the facility is using the evidence-based and
peer reviewed clinical review tool utilized by the insurer which is
designated by the office of [alcoholism and substance abuse] ADDICTION
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD11569-05-4
S. 7288--B 2
services AND SUPPORTS and appropriate to the age of the patient, to
ensure that the outpatient treatment is medically necessary for the
patient. Any utilization review of the treatment provided under this
subparagraph may include a review of all services provided during such
outpatient treatment, including all services provided during the first
four weeks of continuous treatment, not to exceed twenty-eight visits,
of such outpatient treatment. Provided, however, the insurer shall only
deny coverage for any portion of the initial four weeks of continuous
treatment, not to exceed twenty-eight visits, for outpatient treatment
on the basis that such treatment was not medically necessary if such
outpatient treatment was contrary to the evidence-based and peer
reviewed clinical review tool utilized by the insurer which is desig-
nated by the office of [alcoholism and substance abuse] ADDICTION
services AND SUPPORTS. An insured SHALL ONLY HAVE FINANCIAL RESPONSIBIL-
ITIES AS SET OUT IN SUBPARAGRAPH (K) OF THIS PARAGRAPH AND shall not
have any financial obligation to the facility for any treatment under
this subparagraph other than any copayment, coinsurance, or deductible
otherwise required under the policy.
(K) (I) SUCH COVERAGE MAY BE SUBJECT TO ANNUAL DEDUCTIBLES AND COINSU-
RANCE AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT AND AS ARE
CONSISTENT WITH THOSE ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN
POLICY; PROVIDED HOWEVER, THE TOTAL AMOUNT THAT AN INSURED IS REQUIRED
TO PAY OUT-OF-POCKET FOR SUCH SERVICES SHALL BE CAPPED AT AN AMOUNT NOT
TO EXCEED FIVE HUNDRED DOLLARS FOR AN EPISODE OF CARE, REGARDLESS OF THE
INSURED'S DEDUCTIBLE, COPAYMENT, COINSURANCE OR ANY OTHER COST-SHARING
REQUIREMENT. IF UNDER FEDERAL LAW, APPLICATION OF THIS REQUIREMENT WOULD
RESULT IN HEALTH SAVINGS ACCOUNT INELIGIBILITY UNDER 26 USC 223, THIS
REQUIREMENT SHALL APPLY FOR HEALTH SAVINGS ACCOUNT-QUALIFIED HIGH DEDUC-
TIBLE HEALTH PLANS WITH RESPECT TO THE DEDUCTIBLE OF SUCH A PLAN AFTER
THE INSURED HAS SATISFIED THE MINIMUM DEDUCTIBLE UNDER 26 USC 223.
(II) AN EPISODE OF CARE SHALL INCLUDE UP TO SIXTY VISITS WITH THE SAME
TREATMENT PROVIDER.
§ 2. Subparagraphs (C-1) and (E) of paragraph 7 of subsection (l) of
section 3221 of the insurance law, subparagraph (C-1) as added by
section 16 and subparagraph (E) as amended by section 17 of subpart A of
part BB of chapter 57 of the laws of 2019, are amended and a new subpar-
agraph (K) is added to read as follows:
(C-1) A large group policy that provides coverage under this paragraph
shall not impose [copayments or] coinsurance for outpatient substance
use disorder services that exceeds the [copayment or] coinsurance
imposed for a primary care office visit. [Provided that no greater than
one such copayment may be imposed for all services provided in a single
day by a facility licensed, certified or otherwise authorized by the
office of alcoholism and substance abuse services to provide outpatient
substance use disorder services] A LARGE GROUP POLICY THAT PROVIDES
COVERAGE UNDER THIS PARAGRAPH SHALL NOT IMPOSE COPAYMENTS FOR OUTPATIENT
SUBSTANCE USE DISORDER SERVICES.
(E) This subparagraph shall apply to facilities in this state that are
licensed, certified or otherwise authorized by the office of [alcoholism
and substance abuse] ADDICTION services AND SUPPORTS for the provision
of outpatient, intensive outpatient, outpatient rehabilitation and
opioid treatment that are participating in the insurer's provider
network. Coverage provided under this paragraph shall not be subject to
preauthorization. Coverage provided under this paragraph shall not be
subject to concurrent review for the first four weeks of continuous
treatment, not to exceed twenty-eight visits, provided the facility
S. 7288--B 3
notifies the insurer of both the start of treatment and the initial
treatment plan within two business days. The facility shall perform
clinical assessment of the patient at each visit, including periodic
consultation with the insurer at or just prior to the fourteenth day of
treatment to ensure that the facility is using the evidence-based and
peer reviewed clinical review tool utilized by the insurer which is
designated by the office of [alcoholism and substance abuse] ADDICTION
services AND SUPPORTS and appropriate to the age of the patient, to
ensure that the outpatient treatment is medically necessary for the
patient. Any utilization review of the treatment provided under this
subparagraph may include a review of all services provided during such
outpatient treatment, including all services provided during the first
four weeks of continuous treatment, not to exceed twenty-eight visits,
of such outpatient treatment. Provided, however, the insurer shall only
deny coverage for any portion of the initial four weeks of continuous
treatment, not to exceed twenty-eight visits, for outpatient treatment
on the basis that such treatment was not medically necessary if such
outpatient treatment was contrary to the evidence-based and peer
reviewed clinical review tool utilized by the insurer which is desig-
nated by the office of [alcoholism and substance abuse] ADDICTION
services AND SUPPORTS. An insured SHALL ONLY HAVE FINANCIAL RESPONSIBIL-
ITIES AS SET OUT IN SUBPARAGRAPH (K) OF THIS PARAGRAPH AND shall not
have any financial obligation to the facility for any treatment under
this subparagraph other than any copayment, coinsurance, or deductible
otherwise required under the policy.
(K) (I) SUCH COVERAGE MAY BE SUBJECT TO ANNUAL DEDUCTIBLES AND COINSU-
RANCE AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT AND AS ARE
CONSISTENT WITH THOSE ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN
POLICY; PROVIDED HOWEVER, THE TOTAL AMOUNT THAT AN INSURED IS REQUIRED
TO PAY OUT-OF-POCKET FOR SUCH SERVICES SHALL BE CAPPED AT AN AMOUNT NOT
TO EXCEED FIVE HUNDRED DOLLARS FOR AN EPISODE OF CARE REGARDLESS OF THE
INSURED'S DEDUCTIBLE, COPAYMENT, COINSURANCE OR ANY OTHER COST-SHARING
REQUIREMENT. IF UNDER FEDERAL LAW, APPLICATION OF THIS REQUIREMENT WOULD
RESULT IN HEALTH SAVINGS ACCOUNT INELIGIBILITY UNDER 26 USC 223, THIS
REQUIREMENT SHALL APPLY FOR HEALTH SAVINGS ACCOUNT-QUALIFIED HIGH DEDUC-
TIBLE HEALTH PLANS WITH RESPECT TO THE DEDUCTIBLE OF SUCH A PLAN AFTER
THE INSURED HAS SATISFIED THE MINIMUM DEDUCTIBLE UNDER 26 USC 223.
(II) AN EPISODE OF CARE SHALL INCLUDE UP TO SIXTY VISITS WITH THE SAME
TREATMENT PROVIDER.
§ 3. Paragraphs 3-a and 5 of subsection (l) of section 4303 of the
insurance law, paragraph 3-a as added by section 27 and paragraph 5 as
amended by section 28 of subpart A of part BB of chapter 57 of the laws
of 2019, are amended and a new paragraph 11 is added to read as follows:
(3-a) A contract that provides large group coverage under this
subsection shall not impose [copayments or] coinsurance for outpatient
substance use disorder services that exceed the [copayment or] coinsu-
rance imposed for a primary care office visit. [Provided that no greater
than one such copayment may be imposed for all services provided in a
single day by a facility licensed, certified or otherwise authorized by
the office of alcoholism and substance abuse services to provide outpa-
tient substance use disorder services] A LARGE GROUP POLICY THAT
PROVIDES COVERAGE UNDER THIS PARAGRAPH SHALL NOT IMPOSE COPAYMENTS FOR
OUTPATIENT SUBSTANCE USE DISORDER SERVICES.
(5) This paragraph shall apply to facilities in this state that are
licensed, certified or otherwise authorized by the office of [alcoholism
and substance abuse] ADDICTION services AND SUPPORTS for the provision
S. 7288--B 4
of outpatient, intensive outpatient, outpatient rehabilitation and
opioid treatment that are participating in the corporation's provider
network. Coverage provided under this subsection shall not be subject to
preauthorization. Coverage provided under this subsection shall not be
subject to concurrent review for the first four weeks of continuous
treatment, not to exceed twenty-eight visits, provided the facility
notifies the corporation of both the start of treatment and the initial
treatment plan within two business days. The facility shall perform
clinical assessment of the patient at each visit, including periodic
consultation with the corporation at or just prior to the fourteenth day
of treatment to ensure that the facility is using the evidence-based and
peer reviewed clinical review tool utilized by the corporation which is
designated by the office of [alcoholism and substance abuse] ADDICTION
services AND SUPPORTS and appropriate to the age of the patient, to
ensure that the outpatient treatment is medically necessary for the
patient. Any utilization review of the treatment provided under this
paragraph may include a review of all services provided during such
outpatient treatment, including all services provided during the first
four weeks of continuous treatment, not to exceed twenty-eight visits,
of such outpatient treatment. Provided, however, the corporation shall
only deny coverage for any portion of the initial four weeks of contin-
uous treatment, not to exceed twenty-eight visits, for outpatient treat-
ment on the basis that such treatment was not medically necessary if
such outpatient treatment was contrary to the evidence-based and peer
reviewed clinical review tool utilized by the corporation which is
designated by the office of [alcoholism and substance abuse] ADDICTION
services AND SUPPORTS. A subscriber SHALL ONLY HAVE FINANCIAL RESPONSI-
BILITIES AS SET OUT IN PARAGRAPH ELEVEN OF THIS SUBSECTION AND shall not
have any financial obligation to the facility for any treatment under
this paragraph other than any copayment, coinsurance, or deductible
otherwise required under the contract.
(11) (A) SUCH COVERAGE MAY BE SUBJECT TO ANNUAL DEDUCTIBLES AND COIN-
SURANCE AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT AND AS ARE
CONSISTENT WITH THOSE ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN
CONTRACT; PROVIDED HOWEVER, THE TOTAL AMOUNT THAT AN INSURED IS REQUIRED
TO PAY OUT-OF-POCKET FOR SUCH SERVICES SHALL BE CAPPED AT AN AMOUNT NOT
TO EXCEED FIVE HUNDRED DOLLARS FOR AN EPISODE OF CARE REGARDLESS OF THE
INSURED'S DEDUCTIBLE, COPAYMENT, COINSURANCE OR ANY OTHER COST-SHARING
REQUIREMENT. IF UNDER FEDERAL LAW, APPLICATION OF THIS REQUIREMENT WOULD
RESULT IN HEALTH SAVINGS ACCOUNT INELIGIBILITY UNDER 26 USC 223, THIS
REQUIREMENT SHALL APPLY FOR HEALTH SAVINGS ACCOUNT-QUALIFIED HIGH DEDUC-
TIBLE HEALTH PLANS WITH RESPECT TO THE DEDUCTIBLE OF SUCH A PLAN AFTER
THE INSURED HAS SATISFIED THE MINIMUM DEDUCTIBLE UNDER 26 USC 223.
(B) AN EPISODE OF CARE SHALL INCLUDE UP TO SIXTY VISITS WITH THE SAME
TREATMENT PROVIDER.
§ 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
policies and contracts issued, renewed, modified, altered or amended on
and after such date.
