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A03694 Summary:

BILL NOA03694C
 
SAME ASSAME AS S01156-C
 
SPONSORGunther
 
COSPNSRLifton, Sepulveda, Skoufis, Buchwald, Galef, Abinanti, Steck, Rosenthal L
 
MLTSPNSRThiele
 
Amd 210, Ins L
 
Relates to establishing the mental health and substance use disorder parity report act to ensure compliance of insurers and health plans with state and federal requirements for the provision of mental health and substance use disorder treatment and claims.
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A03694 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A3694C
 
SPONSOR: Gunther
  TITLE OF BILL: An act to amend the insurance law, in relation to establishing the mental health and substance use disorder parity report act   PURPOSE OR GENERAL IDEA OF BILL: The purpose of the bill is to require insurers and health plans to submit certain data to the Department of Financial Services and the Commissioner of Health, as a way of measuring compliance with federal and state mental health and substance abuse parity laws. The data will be used by the Department of Financial Services to prepare an annual Mental Health Parity report as part of the annual Consumer Guide.   SUMMARY OF SPECIFIC PROVISIONS: Amends Section 210 of the Insurance Law to require the submission of certain data by insurers and health plans.   JUSTIFICATION: Ensuring New Yorkers have access to care and treatment for mental illness and substance abuse disorders is critical and is the reason New York enacted one of the strongest mental health parity laws in the nation (Timothy's Law) in 2006. New York reaffirmed its commitment to mental health parity when Timothy's Law was made permanent in 2009. Although mental health parity has been the law of the land on the feder- al and state level for a number of years now, the five settlements the New York State Attorney General has reached over the last two years with managed behavioral health companies and health plans or subcontractors for noncompliance is a reminder of the challenges that remain to ensure that the law is properly implemented and enforced. In one of the instances, the Attorney General found that an insurer, through its behavioral health subcontractor issued 64 percent more denials of coverage in mental health and substance abuse cases than in care for physical health conditions requiring previously denied claims to be submitted for review with potential for $31 million in restitution for 15,000 policyholders. In another, the Attorney General found an insurer, through its behavioral subcontractor issued 40 percent more denials for coverage of mental health and substance abuse care and treatment. Furthermore, in one of the investigations, the Attorney General found a health plan rejected inpatient addiction treatment twice as often as inpatient treatment for physical health between 2011 and 2014 and in 2012 alone - the rate of denial was nearly seven times high- er. While such data raises serious concerns, the investigations found further unequal treatment of mental health and substance abuse including charging a higher co-payment for outpatient mental health visits compared to outpatient primary care visits, sometimes twice as high. Other findings included lack of coverage of residential treatment for mental health and substance abuse treatment and adverse determination letters that did not provide adequate information including the medical necessity criteria used to deny treatment. In other cases, the Attorney General found utilization review of mental health and substance abuse treatment was more intensive and frequent as compared for other medical conditions, which required providers to spend an inordinate amount of time justifying necessary and life-saving treatment. An example, from one of the settlements is one pertaining to a 14 year old with an eating disorder who was receiving partial hospitalization until the behavioral health subcontractor for the health plan denied additional days of treatment. The settlement goes on state, "As result, the member had to interrupt treatment while an appeal was lodged on her behalf, exacerbat- ing the symptoms of her illness, and causing her and her family extreme emotional distress." Other states have enacted statutes requiring insurers and health plans to submit data as a mechanism for measuring implementation and compli- ance with federal and state parity laws. It is time New York do the same to provide the public and stakeholders with an annual analysis that will provide critical insight into the following: (A) coverage for mental health and substance abuse services, (B) the adequacy of coverage for mental health and substance abuse conditions, (C) the adequacy of mental health and substance abuse health care provider networks, and (D) the rate of denials for treatment, prior authorization requests, and utilization review for mental health and substance abuse as compared to other medical care. This legislation is needed to assure that New York achieves the full implementation of the parity laws, while also working to reduce the stigma surrounding mental illness and substance abuse, which in and of itself can be one of the most prohibitive barriers for the nearly one in ten individuals who have diagnosable mental health or substance abuse condition in any given year. At time a when many of New York's communi- ties are gripped be an epidemic tied to heroin and abuse of prescription medications, it is imperative we have data that is publicly available measuring compliance with the laws aimed at assuring access to care and treatment.   PRIOR LEGISLATIVE HISTORY: S. 7988 Referred to Insurance Committee   FISCAL IMPLICATIONS: None   EFFECTIVE DATE: This act shall take effect on the sixtieth day.
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A03694 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         3694--C
 
                               2017-2018 Regular Sessions
 
                   IN ASSEMBLY
 
                                    January 30, 2017
                                       ___________
 
        Introduced  by  M.  of  A.  GUNTHER,  LIFTON,  SKOUFIS, BUCHWALD, GALEF,
          ABINANTI, STECK -- Multi-Sponsored by -- M. of A. THIELE -- read  once
          and  referred  to  the Committee 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 --
          again reported from said committee with amendments, 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:
 
     1    Section  1.  Short  title. This act shall be known and may be cited as
     2  the "mental health and substance use disorder parity report act".
     3    § 2. Section 210 of the insurance law  is  amended  by  adding  a  new
     4  subsection (c-1) to read as follows:
     5    (c-1)  Beginning  September  first, two thousand nineteen and annually
     6  thereafter, the superintendent shall include  in  such  guide  a  mental
     7  health and substance use disorder parity report detailing each company's
     8  compliance with federal and state mental health and substance use disor-
     9  der  parity  laws  based  on  each company's record during the preceding
    10  calendar year.  The superintendent shall include  in  such  report,  and
    11  each  company  shall  provide  to  the  superintendent  the  information
    12  required for such guide in a timely fashion, the following information:
    13    (1) Rates of utilization review for mental health  and  substance  use
    14  disorder  claims  as  compared to medical and surgical claims, including
    15  rates of approval and denial, categorized by benefits provided under the
    16  following classifications:  inpatient in-network, inpatient  out-of-net-
    17  work,  outpatient in-network, outpatient out-of-network, emergency care,
    18  and prescription drugs;
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02509-11-8

        A. 3694--C                          2
 
     1    (2) The number of  prior  or  concurrent  authorization  requests  for
     2  mental  health  services and for substance use disorder services and the
     3  number of denials for such requests, compared with the number  of  prior
     4  or  concurrent  authorization requests for medical and surgical services
     5  and  the  number  of  denials for such requests, categorized by the same
     6  classifications identified in paragraph one of this subsection;
     7    (3) The rates of appeals  of  adverse  determinations,  including  the
     8  rates of adverse determinations upheld and overturned, for mental health
     9  claims  and  substance  use  disorder  claims compared with the rates of
    10  appeals of adverse determinations, including the rates of adverse deter-
    11  minations upheld and overturned, for medical and surgical claims;
    12    (4) The  percentage  of  claims  paid  for  in-network  mental  health
    13  services  and  for  substance  use  disorder  services compared with the
    14  percentage of claims paid for in-network medical and  surgical  services
    15  and  the  percentage  of  claims  paid  for out-of-network mental health
    16  services and substance use disorder services compared with the  percent-
    17  age of claims paid for out-of-network medical and surgical services;
    18    (5)  The  number of behavioral health advocates, pursuant to an agree-
    19  ment with the office of the attorney general  if  applicable,  or  staff
    20  available  to  assist  policyholders  with  mental  health  benefits and
    21  substance use disorder benefits;
    22    (6) A comparison of the cost sharing requirements  including  but  not
    23  limited  to co-pays and coinsurance, and the benefit limitations includ-
    24  ing limitations on the scope and duration of coverage, for  medical  and
    25  surgical services, and mental health services and substance use disorder
    26  services;
    27    (7) The number by type of providers licensed to practice in this state
    28  that  provide  services for the treatment and diagnosis of substance use
    29  disorder who are  in-network,  and  the  number  by  type  of  providers
    30  licensed to practice in this state that provide services for the diagno-
    31  sis  and  treatment  of  mental,  nervous  or  emotional  disorders  and
    32  ailments, however defined in a company's policy, who are in-network;
    33    (8) The percentage of providers of  services  for  the  treatment  and
    34  diagnosis  of  substance use disorder who remained participating provid-
    35  ers, and the percentage of providers of services for the  diagnosis  and
    36  treatment of mental, nervous or emotional disorders and ailments, howev-
    37  er  defined in a company's policy, who remained participating providers;
    38  and
    39    (9) Any other data or metric the  superintendent  deems  necessary  to
    40  measure  compliance with mental health and substance use disorder parity
    41  including, but not limited to an evaluation and assessment of:  (i)  the
    42  adequacy   of  the  company's  in-network  mental  health  services  and
    43  substance use disorder provider panels pursuant  to  provisions  of  the
    44  insurance  law  and public health law; and (ii) the company's reimburse-
    45  ment for  in-network  and  out-of-network  mental  health  services  and
    46  substance  use  disorder  services  as compared to the reimbursement for
    47  in-network and out-of-network medical and surgical services.
    48    § 3. Subsection (d) of section 210 of the insurance law, as  added  by
    49  chapter 579 of the laws of 1998, is amended to read as follows:
    50    (d)  Health insurers and entities certified pursuant to article forty-
    51  four of the public health law shall provide annually to the  superinten-
    52  dent  and  the  commissioner  of  health, and the commissioner of health
    53  shall provide to the superintendent, all of  the  information  necessary
    54  for  the  superintendent to produce the annual consumer guide, including
    55  the mental health and substance use disorder parity report.  In  compil-
    56  ing the guide, the superintendent shall make every effort to ensure that

        A. 3694--C                          3
 
     1  the  information  is  presented in a clear, understandable fashion which
     2  facilitates comparisons among individual insurers and entities, and in a
     3  format which lends itself to the widest possible distribution to consum-
     4  ers.  The  superintendent  shall either include the information from the
     5  annual consumer  guide  in  the  consumer  shopping  guide  required  by
     6  subsection  (a)  of  section four thousand three hundred twenty-three of
     7  this chapter or combine the two guides as long as consumers in the indi-
     8  vidual market are provided with the information required  by  subsection
     9  (a) of section four thousand three hundred twenty-three of this chapter.
    10    §  4.  This  act  shall take effect on the sixtieth day after it shall
    11  have become a law, provided, however, effective immediately, the  amend-
    12  ment and/or repeal of any rule or regulation necessary for the implemen-
    13  tation  of this act on its effective date are authorized and directed to
    14  be made and completed on or before such effective date.
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