|SAME AS||SAME AS S01156-C|
|COSPNSR||Lifton, Sepulveda, Skoufis, Buchwald, Galef, Abinanti, Steck, Rosenthal L|
|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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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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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. LBD02509-11-8A. 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 thatA. 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.