N.Y. ISC Law § 343 — New York Code / Act ISC / Article 3 / Section 343
Mental health and substance use disorder parity report
Status: in_force

* § 343. Mental health and substance use disorder parity report. (a)\nBeginning July first, two thousand nineteen and every two years\nthereafter, each insurer providing managed care products, individual\ncomprehensive accident and health insurance or group or blanket\ncomprehensive accident and health insurance, each corporation organized\npursuant to article forty-three of this chapter providing comprehensive\nhealth insurance and each entity licensed pursuant to article forty-four\nof the public health law providing comprehensive health service plans\nshall submit to the superintendent, in a form and manner prescribed by\nthe superintendent, a report detailing the entity's compliance with\nfederal and state mental health and substance use disorder parity laws\nbased on the entity's record during the preceding two calendar years.\nThe superintendent shall publish on the department's website on or\nbefore October first, two thousand nineteen, and every two years\nthereafter, the reports submitted pursuant to this section.\n  (b) Each person required to submit a report under this section shall\ninclude in the report the following information:\n  (1) Rates of utilization review for mental health and substance use\ndisorder claims as compared to medical and surgical claims, including\nrates of approval and denial, categorized by benefits provided under the\nfollowing classifications: inpatient in-network, inpatient\nout-of-network, outpatient in-network, outpatient out-of-network,\nemergency care, and prescription drugs;\n  (2) The number of prior or concurrent authorization requests for\nmental health services and for substance use disorder services and the\nnumber of denials for such requests, compared with the number of prior\nor concurrent authorization requests for medical and surgical services\nand the number of denials for such requests, categorized by the same\nclassifications identified in paragraph one of this subsection;\n  (3) The rates of appeals of adverse determinations, including the\nrates of adverse determinations upheld and overturned, for mental health\nclaims and substance use disorder claims compared with the rates of\nappeals of adverse determinations, including the rates of adverse\ndeterminations upheld and overturned, for medical and surgical claims;\n  (4) The percentage of claims paid for in-network mental health\nservices and for substance use disorder services compared with the\npercentage of claims paid for in-network medical and surgical services\nand the percentage of claims paid for out-of-network mental health\nservices and substance use disorder services compared with the\npercentage of claims paid for out-of-network medical and surgical\nservices;\n  (5) The number of behavioral health advocates, pursuant to an\nagreement with the office of the attorney general if applicable, or\nstaff available to assist policyholders with mental health benefits and\nsubstance use disorder benefits;\n  (6) A comparison of the cost sharing requirements including but not\nlimited to co-pays and coinsurance, and the benefit limitations\nincluding limitations on the scope and duration of coverage, for medical\nand surgical services, and mental health services and substance use\ndisorder services for coverage in the individual, small group, and large\ngroup markets, provided that the comparison captures at least\nseventy-five percent of a company's enrollees in each market;\n  (7) The number by type of providers licensed to practice in this state\nthat provide services for the treatment and diagnosis of substance use\ndisorder who are in-network, and the number by type of providers\nlicensed to practice in this state that provide services for the\ndiagnosis and treatment of mental, nervous or emotional disorders and\nailments, however defined in a company's policy, who are in-network;\n  (8) The percentage of providers of services for the treatment and\ndiagnosis of substance use disorder who remained participating\nproviders, and the percentage of providers of services for the diagnosis\nand treatment of mental, nervous or emotional disorders and ailments,\nhowever defined in a company's policy, who remained participating\nproviders; and\n  (9) Any other data, information, or metric the superintendent deems\nnecessary or useful to measure compliance with mental health and\nsubstance use disorder parity including, but not limited to an\nevaluation and assessment of: (i) the adequacy of the company's\nin-network mental health services and substance use disorder provider\npanels pursuant to provisions of the insurance law and public health\nlaw; and (ii) the company's reimbursement for in-network and\nout-of-network mental health services and substance use disorder\nservices as compared to the reimbursement for in-network and\nout-of-network medical and surgical services.\n  * NB Effective until January 1, 2027\n  * § 343. Mental health and substance-related and addictive disorder\nservices parity report. (a) Beginning July first, two thousand nineteen\nand every two years thereafter, each insurer providing managed care\nproducts, individual comprehensive accident and health insurance or\ngroup or blanket comprehensive accident and health insurance, each\ncorporation organized pursuant to article forty-three of this chapter\nproviding comprehensive health insurance and each entity licensed\npursuant to article forty-four of the public health law providing\ncomprehensive health service plans shall submit to the superintendent,\nin a form and manner prescribed by the superintendent, a report\ndetailing the entity's compliance with federal and state mental health\nand substance-related and addictive disorder services parity laws based\non the entity's record during the preceding two calendar years. The\nsuperintendent shall publish on the department's website on or before\nOctober first, two thousand nineteen, and every two years thereafter,\nthe reports submitted pursuant to this section.\n  (b) Each person required to submit a report under this section shall\ninclude in the report the following information:\n  (1) Rates of utilization review for mental health and\nsubstance-related and addictive disorder claims as compared to medical\nand surgical claims, including rates of approval and denial, categorized\nby benefits provided under the following classifications: inpatient\nin-network, inpatient out-of-network, outpatient in-network, outpatient\nout-of-network, emergency care, and prescription drugs;\n  (2) The number of prior or concurrent authorization requests for\nmental health services and for substance-related and addictive disorder\nservices and the number of denials for such requests, compared with the\nnumber of prior or concurrent authorization requests for medical and\nsurgical services and the number of denials for such requests,\ncategorized by the same classifications identified in paragraph one of\nthis subsection;\n  (3) The rates of appeals of adverse determinations, including the\nrates of adverse determinations upheld and overturned, for mental health\nclaims and substance-related and addictive disorder claims compared with\nthe rates of appeals of adverse determinations, including the rates of\nadverse determinations upheld and overturned, for medical and surgical\nclaims;\n  (4) The percentage of claims paid for in-network mental health\nservices and for substance-related and addictive disorder services\ncompared with the percentage of claims paid for in-network medical and\nsurgical services and the percentage of claims paid for out-of-network\nmental health services and substance-related and addictive disorder\nservices compared with the percentage of claims paid for out-of-network\nmedical and surgical services;\n  (5) The number of behavioral health advocates, pursuant to an\nagreement with the office of the attorney general if applicable, or\nstaff available to assist policyholders with mental health benefits and\nsubstance-related and addictive disorder benefits;\n  (6) A comparison of the cost sharing requirements including but not\nlimited to co-pays and coinsurance, and the benefit limitations\nincluding limitations on the scope and duration of coverage, for medical\nand surgical services, and mental health services and substance-related\nand addictive disorder services for coverage in the individual, small\ngroup, and large group markets, provided that the comparison captures at\nleast seventy-five percent of a company's enrollees in each market;\n  (7) The number by type of providers licensed to practice in this state\nthat provide services for the treatment and diagnosis of\nsubstance-related and addictive disorder who are in-network, and the\nnumber by type of providers licensed to practice in this state that\nprovide services for the diagnosis and treatment of mental, nervous or\nemotional disorders and ailments, however defined in a company's policy,\nwho are in-network;\n  (8) The percentage of providers of services for the treatment and\ndiagnosis of substance-related and addictive disorder who remained\nparticipating providers, and the percentage of providers of services for\nthe diagnosis and treatment of mental, nervous or emotional disorders\nand ailments, however defined in a company's policy, who remained\nparticipating providers; and\n  (9) Any other data, information, or metric the superintendent deems\nnecessary or useful to measure compliance with mental health and\nsubstance-related and addictive disorder parity including, but not\nlimited to an evaluation and assessment of: (i) the adequacy of the\ncompany's in-network mental health services and substance-related and\naddictive disorder provider panels pursuant to provisions of the\ninsurance law and public health law; and (ii) the company's\nreimbursement for in-network and out-of-network mental health services\nand substance-related and addictive disorder services as compared to the\nreimbursement for in-network and out-of-network medical and surgical\nservices.\n  * NB Effective January 1, 2027\n