Source: https://dfs.ny.gov/apps_and_licensing/health_insurers/substance_use_disorder_treatment_guidanc
Timestamp: 2020-04-02 07:00:22
Document Index: 506621978

Matched Legal Cases: ['§3216', '§ 3216', '§ 3221', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3216', '§ 3221', '§ 3221', '§ 3216']

Q. Do Insurance Law §§3216(i)(30)(D), 3221(l)(6)(D) and 4303(k)(4) apply to detoxification admissions?
Q. Do the Insurance Law §§ 3216(i)(31-a), 3221(l)(7-b) and 4303(l-2) requirements for coverage of an emergency supply of medication for a substance use disorder without preauthorization and the Insurance Law §§ 3221(l)(7-a) and 4303(l-1) requirements for coverage for medication for the detoxification or maintenance treatment of a substance use disorder under large group policies and contracts apply to over-the-counter medication?
Utilization Review of Inpatient Substance Use Disorder Treatment
Q. Do the amendments to Insurance Law §§ 3216(i)(30), 3221(l)(6)(A), and 4303(k)(1) permit health plans to impose utilization review requirements on inpatient and residential substance use disorder treatment as along as the processes, strategies, evidentiary standards, or other factors used in applying a non-quantitative treatment limitation to mental health or substance use disorder benefits in a classification are comparable to, and applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to inpatient medical surgical/benefits?
Q. Do the limitations on utilization review during the first 14 days of an inpatient admission described in Insurance Law §§ 3216(i)(30)(D), 3221(l)(6)(D) and 4303(k)(4) apply to immediate readmissions following discharge?
Q. Does the 14 day count for the limitation on utilization review include transfers from one inpatient facility to another or does each inpatient facility have its own 14 day count?
Q. If an inpatient or residential facility fails to provide a health plan with notice of an admission and a treatment plan pursuant to Insurance Law §§ 3216(i)(30)(D), 3221(l)(6)(D) or 4303(k)(4) within 48 hours of admission, can the health plan begin concurrent review of services immediately upon learning of the admission, even if it is during the initial 14 day period? Also, may the health plan retrospectively deny any care provided prior to learning of the admission?
Q. Is retrospective utilization review permitted under Insurance Law §§ 3216(i)(30)(D), 3221(l)(6)(D) and 4303(k)(4)?
Q. Are health plans required to cover days 1 – 14 of an inpatient admission pursuant to Insurance Law §§ 3216(i)(30)(D), 3221(l)(6)(D) and 4303(k)(4) if they subsequently determine that some or all of days 1-14 were not medically necessary?
Q. If a health plan denies an inpatient admission in whole or in part pursuant to Insurance Law §§ 3216(i)(30)(D), 3221(l)(6)(D) and 4303(k)(4) does the insured have a financial obligation to the facility other than any copayment, coinsurance or deductible?
Q. Do the provisions in Insurance Law §§ 3216(i)(30)(D), 3221(l)(6)(D) and 4303(k)(4) apply to all inpatient facilities?
Emergency Supply of a Medication
Q. Is retrospective utilization review permitted under Insurance Law §§ 3216(i)(31-a), 3221(l)(7-b) and 4303(l-2)?
Q. What is the definition of an emergency condition with respect to the requirement for coverage of an emergency supply of medication for a substance use disorder under Insurance Law §§ 3216(i)(31-a), 3221(l)(7-b) and 4303(l-2)?
Q. Can health plans limit the number of times they will cover an emergency supply of medication for a substance use disorder under Insurance Law §§ 3216(i)(31-a), 3221(l)(7-b) and 4303(l-2)?
Q. What are a health plan’s options for charging a copayment for a limited initial seven-day supply of a schedule II, III or IV opioid drug under Insurance Law §§ 3216(i)(33), 3221(k)(21) and 4303(qq)?
Q. Under Insurance Law §§ 3216(i)(33), 3221(k)(21) and 4303(qq), if an insured obtains an initial 7-day fill of a schedule II, III or IV opioid drug, and the health plan charged a copayment that was proportional to the supply dispensed, and the insured then fills a prescription for a 30-day supply of the drug within 30 days of the 7-day fill, how would the copayment for the 30-day supply be applied?
Q. Under Insurance Law §§ 3216(i)(33), 3221(k)(21) and 4303(qq), if an insured obtains an initial 7-day fill of a schedule II, III or IV opioid drug, and the health plan charged a copayment for a full 30-day supply, and the insured then fills a prescription for a 30-day supply of the drug within 30 days of the 7-day fill, how would the copayment for the 30-day supply be applied? Assume that the copayment is $30 for a 30-day supply.
Q. If an insured obtains an initial 7-day fill of a schedule II, III or IV opioid drug, and then fills a prescription for a 30-day supply of the drug within 30 days after the 7-day fill, but at a different pharmacy than the 7-day fill, would the above copayment prorating be applicable since the 30-day prescription was filled at a different pharmacy?
Q. If an insured obtains an initial 7-day fill of a schedule II, III or IV opioid drug, and then fills a prescription for a 30-day supply of the drug more than 30 days after the 7-day fill, what copayment may be charged? Assume that the copayment is $30 for a 30-day supply.
Q. What are a health plan’s options for charging a copayment for a 5-day emergency supply of a medication for the treatment of substance use disorder where an emergency condition exists, including a prescribed drug associated with opioid withdrawal or stabilization under Insurance Law §§ 3216(i)(31-a), 3221(l)(7-b) and 4303(l-2)?
Q. Under Insurance Law §§ 3216(i)(31-a), 3221(l)(7-b) and 4303(l-2), if an insured obtains an initial 5-day emergency supply of a medication for the treatment of a substance use disorder where an emergency condition exists, and the health plan charged a copayment that was proportional to the supply dispensed, and the insured then fills a prescription for a 30-day supply of the drug within 30 days of the 5-day fill, how would the copayment for the 30-day supply be applied?
Q. Under Insurance Law §§ 3216(i)(31-a), 3221(l)(7-b) and 4303(l-2), if an insured obtains an initial 5-day emergency supply of a medication for the treatment of a substance use disorder where an emergency condition exists, and the health plan charged a copayment for a full 30-day supply, and the insured then fills a prescription for a 30-day supply of the drug within 30 days of the 5-day fill, how would the copayment for the 30-day supply be applied? Assume that the copayment is $30 for a 30-day supply.
Q. If an insured obtains a 5-day emergency supply of a medication for the treatment of a substance use disorder where an emergency condition exists, and then fills a prescription for a 30-day supply of the drug within 30 days after the 5-day fill, but at a different pharmacy than the 5-day fill, would the above copayment prorating be applicable since the 30-day prescription was filled at a different pharmacy?
Q. If an insured obtains an initial 5-day emergency supply of a medication for the treatment of substance use disorder where an emergency condition exists, and then the insured fills a prescription for a 30-day supply of the drug more than 30 days after the 5-day fill, what copayment may be charged? Assume that the copayment is $30 for a 30 day supply.
Q. If a large group policy or contract does not include coverage for prescription drugs, are there restrictions on the cost-sharing that can be imposed on medications for detoxification or maintenance treatment of a substance use disorder under Insurance Law §§ 3221(7-a) and 4303(l-1)?
Q. If a large group policy does not include coverage for prescription drugs, can a health plan use a formulary to specify the medications it will cover for detoxification or maintenance treatment of a substance use disorder under Insurance Law §§ 3221(l)(7-a) and 4303(l-1)?
Q. Insurance Law §§ 3216(i)(30)(D), 3221(l)(6)(D) and 4303(k)(4) require facilities that are certified by OASAS and participate in a health plan’s network to, with respect to an inpatient admission for treatment of substance use disorder, perform daily clinical review of the patient, including the periodic consultation with the health plan to ensure that the facility is using the evidence-based and peer reviewed clinical review tool utilized by the health plan which is designated by OASAS and appropriate to the age of the patient, to ensure that the inpatient treatment is medically necessary for the patient. How will the provider community be made aware of this requirement?
Q. Does DFS have a count of the total universe of individuals the opioid legislation would (or could potentially) impact?
Q. What is the State’s vision for Value Based Purchasing schemes to fund substance use disorder treatment?
Q.How will the State be monitoring the impact of the opioid legislation (e.g. readmission rates and engagement in outpatient services)? Will there be increases in the health plans’ premiums to defray increased costs if there is not an offset in the readmission rate?