Lifton, Sepulveda, Skoufis, Buchwald, Galef, Abinanti, Steck, Rosenthal L
MLTSPNSR
Epstein, Thiele
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.
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.
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.
