S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1763
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             January 13, 2025
                                ___________
 
 Introduced  by  Sens.  FERNANDEZ,  ADDABBO,  S. RYAN  --  read twice and
   ordered printed, and when printed to be committed to the Committee  on
   Insurance
 
 AN  ACT  to amend the insurance law, in relation to certain cost sharing
   fees for outpatient treatment at a substance use treatment program

   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
 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
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03320-01-5
              

 S. 1763                             2
 
 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 deduct-
 ible] otherwise required under the policy.
   (K) FOR A SUBSTANCE USE DISORDER OUTPATIENT TREATMENT EPISODE OF  CARE
 BY  A PROVIDER LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED BY THE OFFICE
 OF ADDICTION SERVICES AND SUPPORTS, AN INSURED SHALL ONLY BE RESPONSIBLE
 FOR A COST SHARING FEE NOT TO EXCEED FIVE HUNDRED  DOLLARS.  AN  INSURER
 PROVIDING  COVERAGE  UNDER  THIS  PARAGRAPH SHALL BE RESPONSIBLE FOR ALL
 OTHER FINANCIAL OBLIGATIONS TO THE  FACILITY.  AN  EPISODE  OF  CARE  IS
 DEFINED TO 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
 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
 S. 1763                             3
 
 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 deduct-
 ible] otherwise required under the policy.
   (K) FOR A SUBSTANCE USE DISORDER OUTPATIENT TREATMENT EPISODE OF  CARE
 BY  A PROVIDER LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED BY THE OFFICE
 OF ADDICTION SERVICES AND SUPPORTS, AN INSURED SHALL ONLY BE RESPONSIBLE
 FOR A COST SHARING FEE NOT TO EXCEED FIVE HUNDRED  DOLLARS.  AN  INSURER
 PROVIDING  COVERAGE  UNDER  THIS  PARAGRAPH SHALL BE RESPONSIBLE FOR ALL
 OTHER FINANCIAL OBLIGATIONS TO THE  FACILITY.  AN  EPISODE  OF  CARE  IS
 DEFINED TO 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
 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
 S. 1763                             4
 
 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) FOR A SUBSTANCE USE DISORDER OUTPATIENT TREATMENT EPISODE OF CARE
 BY A PROVIDER LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED BY THE  OFFICE
 OF ADDICTION SERVICES AND SUPPORTS, AN INSURED SHALL ONLY BE RESPONSIBLE
 FOR  A  COST  SHARING FEE NOT TO EXCEED FIVE HUNDRED DOLLARS. AN INSURER
 PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL  BE  RESPONSIBLE  FOR  ALL
 OTHER  FINANCIAL  OBLIGATIONS  TO  THE  FACILITY.  AN EPISODE OF CARE IS
 DEFINED TO 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.