S05909 Summary:

BILL NOS05909
 
SAME ASSAME AS A03276
 
SPONSORKAMINSKY
 
COSPNSRKENNEDY, REICHLIN-MELNICK
 
MLTSPNSR
 
Amd §§3216, 3221 & 4303, Ins L
 
Prohibits the application of fail-first or step therapy protocols to coverage for the diagnosis and treatment of mental health conditions.
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S05909 Actions:

BILL NOS05909
 
03/22/2021REFERRED TO INSURANCE
05/18/20211ST REPORT CAL.1165
05/20/20212ND REPORT CAL.
05/24/2021ADVANCED TO THIRD READING
06/08/2021PASSED SENATE
06/08/2021DELIVERED TO ASSEMBLY
06/08/2021referred to insurance
01/05/2022died in assembly
01/05/2022returned to senate
01/05/2022REFERRED TO INSURANCE
04/25/20221ST REPORT CAL.764
04/26/20222ND REPORT CAL.
04/27/2022ADVANCED TO THIRD READING
05/24/2022SUBSTITUTED BY A3276
 A03276 AMEND= Gunther
 01/22/2021referred to insurance
 01/05/2022referred to insurance
 01/20/2022reported
 01/20/2022advanced to third reading cal.293
 04/05/2022passed assembly
 04/05/2022delivered to senate
 04/05/2022REFERRED TO INSURANCE
 05/24/2022SUBSTITUTED FOR S5909
 05/24/20223RD READING CAL.764
 05/24/2022PASSED SENATE
 05/24/2022RETURNED TO ASSEMBLY
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S05909 Committee Votes:

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S05909 Floor Votes:

There are no votes for this bill in this legislative session.
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S05909 Memo:

Memo not available
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S05909 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          5909
 
                               2021-2022 Regular Sessions
 
                    IN SENATE
 
                                     March 22, 2021
                                       ___________
 
        Introduced  by Sen. KAMINSKY -- 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 prohibiting the appli-
          cation of fail-first or step therapy protocols  to  coverage  for  the
          diagnosis and treatment of mental health conditions

          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section  1.  Subparagraphs  (A),  (C)  and  (E)  of  paragraph  35  of
     2  subsection (i) of section 3216 of the insurance law, as added by section
     3  8 of subpart A of part BB of chapter 57 of the laws of 2019, are amended
     4  to read as follows:
     5    (A)  Every  policy delivered or issued for delivery in this state that
     6  provides coverage for inpatient hospital care or coverage for  physician
     7  services  shall  provide  coverage  for  the  diagnosis and treatment of
     8  mental health conditions as follows:
     9    (i) where the policy provides coverage for  inpatient  hospital  care,
    10  benefits  for inpatient care in a hospital as defined by subdivision ten
    11  of section 1.03 of the mental hygiene law and  benefits  for  outpatient
    12  care  provided  in  a  facility  issued  an operating certificate by the
    13  commissioner of mental health pursuant  to  the  provisions  of  article
    14  thirty-one  of  the mental hygiene law, or in a facility operated by the
    15  office of mental health, or, for care provided in other states, to simi-
    16  larly licensed or certified hospitals or facilities; and
    17    (ii) where the policy provides coverage for physician services,  bene-
    18  fits  for  outpatient  care  provided  by a psychiatrist or psychologist
    19  licensed to practice in this state, a licensed  clinical  social  worker
    20  who  meets  the  requirements  of  subparagraph (D) of paragraph four of
    21  subsection (1) of section three thousand two hundred twenty-one of  this
    22  article,  a  nurse practitioner licensed to practice in this state, or a
    23  professional corporation  or  university  faculty  practice  corporation
    24  thereof, including outpatient drug coverage.
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02946-01-1

        S. 5909                             2
 
     1    (C)  Coverage  under this paragraph shall not apply financial require-
     2  ments or treatment limitations to mental health benefits, including drug
     3  coverage, that are  more  restrictive  than  the  predominant  financial
     4  requirements  and  treatment  limitations  applied  to substantially all
     5  medical and surgical benefits covered by the policy. Coverage under this
     6  paragraph,  including  drug  coverage, shall not apply any fail-first or
     7  step therapy protocol, as defined by section four thousand nine  hundred
     8  of this chapter.
     9    (E) For purposes of this paragraph:
    10    (i)  "financial requirement" means deductible, copayments, coinsurance
    11  and out-of-pocket expenses;
    12    (ii) "predominant" means that a  financial  requirement  or  treatment
    13  limitation  is  the  most  common  or  frequent of such type of limit or
    14  requirement;
    15    (iii) "treatment limitation" means limits on the frequency  of  treat-
    16  ment, number of visits, days of coverage, or other similar limits on the
    17  scope  or  duration  of treatment and includes nonquantitative treatment
    18  limitations such as: medical management standards limiting or  excluding
    19  benefits  based  on medical necessity, or based on whether the treatment
    20  is experimental or investigational; formulary  design  for  prescription
    21  drugs;  network tier design; standards for provider admission to partic-
    22  ipate in a network, including reimbursement rates; methods for determin-
    23  ing usual, customary, and reasonable charges; [fail-first or step thera-
    24  py protocols;] exclusions based on  failure  to  complete  a  course  of
    25  treatment; and restrictions based on geographic location, facility type,
    26  provider  specialty, and other criteria that limit the scope or duration
    27  of benefits for services provided under the policy; and
    28    (iv) "mental health condition" means any  mental  health  disorder  as
    29  defined  in  the  most  recent edition of the diagnostic and statistical
    30  manual of mental disorders or the most recent edition of another  gener-
    31  ally recognized independent standard of current medical practice such as
    32  the international classification of diseases.
    33    §  2.  Subparagraphs (A), (C) and (E) of paragraph 5 of subsection (l)
    34  of section 3221 of the insurance law, subparagraph  (A)  as  amended  by
    35  section 13 of subpart A of part BB of chapter 57 of the laws of 2019 and
    36  subparagraphs (C) and (E) as added by section 14 of subpart A of part BB
    37  of chapter 57 of the laws of 2019, are amended to read as follows:
    38    (A) Every insurer delivering a group or school blanket policy or issu-
    39  ing  a group or school blanket policy for delivery, in this state, which
    40  provides coverage for inpatient hospital care or coverage for  physician
    41  services  shall  provide  coverage  for  the  diagnosis and treatment of
    42  mental health conditions and:
    43    (i) where the policy provides coverage for  inpatient  hospital  care,
    44  benefits  for inpatient care in a hospital as defined by subdivision ten
    45  of section 1.03 of the mental hygiene law and  benefits  for  outpatient
    46  care  provided  in  a  facility  issued  an operating certificate by the
    47  commissioner of mental health pursuant  to  the  provisions  of  article
    48  thirty-one  of  the mental hygiene law, or in a facility operated by the
    49  office of mental health or, for care provided in other states, to  simi-
    50  larly licensed or certified hospitals or facilities; and
    51    (ii)  where  the  policy  provides coverage for physician services, it
    52  shall include benefits for outpatient care provided by a psychiatrist or
    53  psychologist licensed to practice in this  state,  a  licensed  clinical
    54  social  worker  who  meets the requirements of subparagraph (D) of para-
    55  graph four of this subsection, a nurse practitioner licensed to practice

        S. 5909                             3

     1  in this state, or a professional corporation or university faculty prac-
     2  tice corporation thereof, including outpatient drug coverage.
     3    (C)  Coverage  under this paragraph shall not apply financial require-
     4  ments or treatment limitations to mental health benefits, including drug
     5  coverage, that are  more  restrictive  than  the  predominant  financial
     6  requirements  and  treatment  limitations  applied  to substantially all
     7  medical and surgical benefits covered by the policy. Coverage under this
     8  paragraph, including drug coverage, shall not apply  any  fail-first  or
     9  step  therapy protocol, as defined by section four thousand nine hundred
    10  of this chapter.
    11    (E) For purposes of this paragraph:
    12    (i) "financial requirement" means deductible, copayments,  coinsurance
    13  and out-of-pocket expenses;
    14    (ii)  "predominant"  means  that  a financial requirement or treatment
    15  limitation is the most common or frequent  of  such  type  of  limit  or
    16  requirement;
    17    (iii)  "treatment  limitation" means limits on the frequency of treat-
    18  ment, number of visits, days of coverage, or other similar limits on the
    19  scope or duration of treatment and  includes  nonquantitative  treatment
    20  limitations  such as: medical management standards limiting or excluding
    21  benefits based on medical necessity, or based on whether  the  treatment
    22  is  experimental  or  investigational; formulary design for prescription
    23  drugs; network tier design; standards for provider admission to  partic-
    24  ipate in a network, including reimbursement rates; methods for determin-
    25  ing usual, customary, and reasonable charges; [fail-first or step thera-
    26  py  protocols;]  exclusions  based  on  failure  to complete a course of
    27  treatment; and restrictions based on geographic location, facility type,
    28  provider specialty, and other criteria that limit the scope or  duration
    29  of benefits for services provided under the policy; and
    30    (iv)  "mental  health  condition"  means any mental health disorder as
    31  defined in the most recent edition of  the  diagnostic  and  statistical
    32  manual  of mental disorders or the most recent edition of another gener-
    33  ally recognized independent standard of current medical practice such as
    34  the international classification of diseases.
    35    § 3. Paragraphs 2 and 4,  and  subparagraph  (C)  of  paragraph  6  of
    36  subsection  (g)  of  section  4303  of the insurance law, paragraph 2 as
    37  added by section 22 of subpart A of part BB of chapter 57 of the laws of
    38  2019, and paragraph 4 and subparagraph (C) of paragraph 6  as  added  by
    39  section  23  of  subpart A of part BB of chapter 57 of the laws of 2019,
    40  are amended the read as follows:
    41    (2) where the contract provides coverage for physician services  bene-
    42  fits  for  outpatient  care  provided  by a psychiatrist or psychologist
    43  licensed to practice in this state, a licensed  clinical  social  worker
    44  who  meets  the  requirements of subsection (n) of this section, a nurse
    45  practitioner licensed to practice on this state, or professional  corpo-
    46  ration  or  university  faculty  practice corporation thereof, including
    47  outpatient drug coverage.
    48    (4) Coverage under this subsection shall not apply financial  require-
    49  ments or treatment limitations to mental health benefits, including drug
    50  coverage,  that  are  more  restrictive  than  the predominant financial
    51  requirements and treatment  limitations  applied  to  substantially  all
    52  medical  and  surgical benefits covered by the contract.  Coverage under
    53  this paragraph, including drug coverage, shall not apply any  fail-first
    54  or  step  therapy  protocol,  as  defined  by section four thousand nine
    55  hundred of this chapter.

        S. 5909                             4
 
     1    (C) "treatment limitation" means limits on the frequency of treatment,
     2  number of visits, days of coverage, or other similar limits on the scope
     3  or duration of treatment and includes nonquantitative treatment  limita-
     4  tions  such as: medical management standards limiting or excluding bene-
     5  fits  based  on  medical necessity, or based on whether the treatment is
     6  experimental  or  investigational;  formulary  design  for  prescription
     7  drugs;  network tier design; standards for provider admission to partic-
     8  ipate in a network, including reimbursement rates; methods for determin-
     9  ing usual, customary, and reasonable charges; [fail-first or step thera-
    10  py protocols;] exclusions based on  failure  to  complete  a  course  of
    11  treatment; and restrictions based on geographic location, facility type,
    12  provider  specialty, and other criteria that limit the scope or duration
    13  of benefits for services provided under the contract; and
    14    § 4. This act shall take effect immediately and  shall  apply  to  all
    15  policies  and contracts issued, renewed, modified, altered or amended on
    16  or after such date.
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