Source: https://www.nysenate.gov/legislation/bills/2017/a3694/amendment/a
Timestamp: 2020-04-09 20:15:47
Document Index: 703533215

Matched Legal Cases: ['§210', '§ 2', '§  156', '§ 3', '§ 4', '§  5', '§  146', '§  2590', '§ 54', '§  156', '§  3', '§ 5', '§ 146', '§ 2590', '§  54', '§ 156', '§ 2', '§ 3']

NY State Assembly Bill A3694A
assembly Bill A3694A
Relates to establishing the mental health and substance use parity report act
Get Status Alerts for A3694A
Dec 21, 2018 approval memo.13
signed chap.455
Dec 11, 2018 delivered to governor
3rd reading cal.2106
substituted for s1156c
Jun 18, 2018 referred to rules
Jun 14, 2018 ordered to third reading rules cal.218
rules report cal.218
Jun 13, 2018 reported referred to rules
Jun 06, 2018 reported referred to codes
May 31, 2018 print number 3694c
May 31, 2018 amend and recommit to insurance
Jan 31, 2018 print number 3694b
Jan 31, 2018 amend and recommit to insurance
Jun 08, 2017 print number 3694a
Jun 08, 2017 amend (t) and recommit to insurance
Jan 30, 2017 referred to insurance
A3694C
A3694 - Details
Amd §210, Ins L
A3694 - Summary
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.
A3694 - Bill Text download pdf
AN ACT to amend the insurance  law,  in  relation  to  establishing  the
mental health and substance abuse parity report act
the "mental health and substance abuse parity report act".
§ 2. Subsection (a) of section 210 of the insurance law, as amended by
chapter 579 of the laws of 1998, is amended to read as follows:
(a)  The  superintendent shall annually publish on or before September
first, nineteen hundred ninety-nine, and annually thereafter, a consumer
guide to insurers providing managed care products,  individual  accident
and  health  insurance or group or blanket accident and health insurance
and entities licensed pursuant  to  article  forty-four  of  the  public
health  law providing comprehensive health service plans which includes,
in detail, a ranking from best to worst based upon each company's  claim
processing or medical payments record during the preceding calendar year
using  criteria  available  to  the  department,  adjusted for volume of
coverage provided. Such ranking shall also take into  consideration  the
corresponding  total  number  or  percentage of claims denied which were
reversed or compromised after intervention by  the  department  and  the
department  of  health,  consumer  complaints  to the department and the
department of health, violations of section three thousand  two  hundred
twenty-four-a  of  this  chapter  and  other  pertinent data which would
permit the department to objectively determine a company's  performance.
The  department  in  publishing  such  consumer  guide shall publish one
state-wide guide or no more than five regional guides so as  to  facili-
tate comparisons among individual insurers and entities within a service
market  area. Such rankings shall be printed in a format which ranks all
health insurers and all entities certified pursuant  to  article  forty-
LBD02509-02-7
A. 3694                             2
four  of  the public health law in one combined list. THE CONSUMER GUIDE
ON OR BEFORE SEPTEMBER FIRST, TWO THOUSAND EIGHTEEN AND ANNUALLY  THERE-
AFTER, SHALL INCLUDE A MENTAL HEALTH PARITY REPORT THAT INCLUDES A RANK-
ING  FROM BEST TO WORST BASED UPON EACH COMPANY'S COMPLIANCE WITH MENTAL
HEALTH AND SUBSTANCE ABUSE PARITY LAWS BASED ON  EACH  COMPANY'S  RECORD
DURING  THE  PRECEDING  CALENDAR  YEAR  USING  CRITERIA AVAILABLE TO THE
DEPARTMENT, INCLUDING, BUT NOT LIMITED TO, INFORMATION REQUIRED BY  THIS
SUBSECTION  AND  SUBSECTIONS  (B), (C) AND (D) OF THIS SECTION. IN ADDI-
TION, NOTWITHSTANDING SUCH REQUIREMENTS AND ANY LAW TO THE CONTRARY, THE
DATA TO BE INCLUDED IN THE MENTAL HEALTH PARITY REPORT AND COLLECTED  BY
THE  SUPERINTENDENT  AND  THE  COMMISSIONER OF HEALTH, FOR SUCH PURPOSES
(1) ANNUAL MENTAL HEALTH AND SUBSTANCE ABUSE PARITY COMPLIANCE  REPORT
FROM  EACH  INSURER  OUTLINING  HOW  IT COMPLIES WITH TIMOTHY'S LAW, THE
INSURANCE LAW PROVISIONS REGARDING SUBSTANCE ABUSE AND EATING  DISORDERS
AND  THE  PAUL  WELLSTONE  AND  PETE  DOMENICI  MENTAL HEALTH PARITY AND
ADDICTION EQUITY ACT OF TWO THOUSAND EIGHT;
(2) RATES OF UTILIZATION REVIEW FOR MENTAL HEALTH AND SUBSTANCE  ABUSE
CLAIMS VERSUS PHYSICAL HEALTH, INCLUDING RATE OF DENIAL;
(3)  THE  NUMBER OF PRIOR AUTHORIZATION REQUESTS FOR MENTAL HEALTH AND
SUBSTANCE ABUSE SERVICES AND THE NUMBER OF DENIALS  FOR  SUCH  REQUESTS,
COMPARED  WITH  THE  NUMBER  OF  PRIOR  AUTHORIZATION REQUESTS FOR OTHER
HEALTH CARE SERVICES AND THE NUMBER OF DENIALS FOR SUCH REQUESTS,  WHICH
SHALL ALSO INCLUDE THE RATES OF INTERNAL AND EXTERNAL APPEALS, INCLUDING
RATES  OF  APPEALS UPHELD AND OVERTURNED, SPECIFICALLY FOR MENTAL HEALTH
AND SUBSTANCE ABUSE;
(4) THE PERCENTAGE OF CLAIMS PAID FOR OUT-OF-NETWORK MENTAL HEALTH AND
SUBSTANCE ABUSE SERVICES COMPARED WITH THE PERCENTAGE OF CLAIMS PAID FOR
OTHER TYPES OF OUT-OF-NETWORK HEALTH CARE AND SURGICAL SERVICES;
(5) THE MEDICAL NECESSITY CRITERIA IT USES TO MAKE PRIOR AUTHORIZATION
OR ADVERSE DETERMINATIONS, WHICH IN CONJUNCTION  MUST  BE  CONSPICUOUSLY
POSTED  FOR  POLICYHOLDERS  AND  PROVIDERS  TO BE ABLE TO REVIEW WITHOUT
MAKING A REQUEST;
(6) THE NUMBER OF COMPLAINTS RECEIVED FROM POLICY HOLDERS WITH RESPECT
TO COVERAGE FOR MENTAL ILLNESS AND SUBSTANCE ABUSE,  WITHOUT  PATIENT-I-
DENTIFYING  INFORMATION.    UPON  REQUEST FROM A DEPARTMENT, THE INSURER
WILL PROVIDE A COPY OF THE INDIVIDUAL COMPLAINT TO SUCH DEPARTMENT;
(7) THE NUMBER OF BEHAVIORAL HEALTH ADVOCATES, PURSUANT TO  AN  AGREE-
MENT WITH THE OFFICE OF ATTORNEY GENERAL IF APPLICABLE, OR STAFF ON HAND
TO  ASSIST  POLICYHOLDERS  WITH  BENEFITS FOR MENTAL HEALTH OR SUBSTANCE
(8) THE NETWORK ADEQUACY OF INSURERS AND HEALTH PLANS, WHICH IN  ADDI-
TION TO THE REQUIREMENTS OF SUBSECTION (A) OF SECTION THREE THOUSAND TWO
HUNDRED  FORTY-ONE  OF  THIS CHAPTER AND SUBSECTION (C) OF THIS SECTION,
SHALL CONSIST OF VERIFYING THE MENTAL HEALTH AND SUBSTANCE ABUSE PROVID-
ERS LISTED IN AN INSURERS OR  HEALTH  PLANS  PROVIDER  DIRECTORY  AS  IN
NETWORK.  SUCH  VERIFICATION  SHALL BE PROVIDED BY THE INSURER OR HEALTH
PLAN, ON AN ANNUAL BASIS, BY PROVIDING ITS  LIST  OF  IN-NETWORK  MENTAL
HEALTH  AND  SUBSTANCE  ABUSE  PROVIDERS  AND  THE NUMBER OF CLAIMS EACH
PROVIDER HAS SUBMITTED WITHIN THE PAST TWELVE MONTHS. FOR PROVIDERS THAT
HAVE HAD NO CLAIMS IN THE PAST TWELVE MONTHS, THE INSURER OR HEALTH PLAN
MUST PROVIDE AN ATTESTATION THAT SUCH PROVIDER  IS  STILL  PART  OF  THE
NETWORK. FOR QUALIFIED HEALTH PLANS OFFERED ON NEW YORK STATE OF HEALTH,
THE  DEPARTMENT OF HEALTH SHALL REVIEW THE NETWORK ADEQUACY TO ENSURE IT
IS CONSISTENT WITH 45 CFR §  156.230  AND  THE  DEPARTMENT  OF  HEALTH'S
MANAGED  CARE  NETWORK ADEQUACY STANDARD AND, IN ADDITION, SHALL CONSIST
A. 3694                             3
OF VERIFYING THE MENTAL HEALTH AND SUBSTANCE ABUSE PROVIDERS LISTED IN A
QUALIFIED HEALTH PLANS PROVIDER DIRECTORY AS IN NETWORK. SUCH  VERIFICA-
TION  SHALL  BE PROVIDED BY A QUALIFIED HEALTH PLAN, ON AN ANNUAL BASIS,
BY  PROVIDING  ITS  LIST OF IN-NETWORK MENTAL HEALTH AND SUBSTANCE ABUSE
PROVIDERS AND THE NUMBER OF CLAIMS EACH PROVIDER  HAS  SUBMITTED  WITHIN
THE  PAST  TWELVE  MONTHS. FOR PROVIDERS THAT HAVE NO CLAIMS IN THE PAST
TWELVE MONTHS, THE QUALIFIED HEALTH PLAN  MUST  PROVIDE  AN  ATTESTATION
THAT SUCH PROVIDER IS STILL PART OF THE NETWORK; AND
(9) ANY OTHER DATA OR METRIC THE SUPERINTENDENT OR THE COMMISSIONER OF
HEALTH  DEEMS  IS NECESSARY TO MEASURE COMPLIANCE WITH MENTAL HEALTH AND
SUBSTANCE ABUSE PARITY.
§ 3. Paragraph 2 of subsection (c) of section  210  of  the  insurance
law,  as added by chapter 579 of the laws of 1998, is amended to read as
(2) the percentage of primary care physicians who remained participat-
ing providers, provided however,  that  such  percentage  shall  exclude
voluntary  terminations due to physician retirement, relocation or other
similar reasons, AND THE  PERCENTAGE  OF  MENTAL  HEALTH  PROFESSIONALS,
DEFINED  AS  PHYSICIANS WHO ARE LICENSED PURSUANT TO ARTICLE ONE HUNDRED
THIRTY-ONE OF THE EDUCATION LAW WHO ARE DIPLOMATS OF THE AMERICAN  BOARD
OF  PSYCHIATRY  AND  NEUROLOGY  OR  ARE ELIGIBLE TO BE CERTIFIED BY THAT
BOARD, OR ARE CERTIFIED BY THE AMERICAN OSTEOPATHIC BOARD  OF  NEUROLOGY
AND  PSYCHIATRY  OR ARE ELIGIBLE TO BE CERTIFIED BY THAT BOARD, A SOCIAL
WORKER LICENSED PURSUANT TO ARTICLE ONE HUNDRED FIFTY-FOUR OF THE EDUCA-
TION LAW OR A PSYCHOLOGIST LICENSED  PURSUANT  TO  ARTICLE  ONE  HUNDRED
FIFTY-THREE  OF THE EDUCATION LAW, WHO REMAINED AS PARTICIPATING PROVID-
ERS AND THE NUMBER OF CLAIMS EACH TYPE OF MENTAL HEALTH PROFESSIONAL HAS
SUBMITTED IN THE LAST TWELVE MONTHS AND  THE  NUMBER  OF  MENTAL  HEALTH
PROFESSIONALS,  IF  ANY,  WHO HAVE NOT HAD ANY CLAIMS IN THE LAST TWELVE
§ 4. Subsection (d) of section 210 of the insurance law, as  added  by
(d)  Health insurers and entities certified pursuant to article forty-
four of the public health law shall provide annually to the  superinten-
dent  and  the  commissioner  of  health, and the commissioner of health
shall provide to the superintendent, all of  the  information  necessary
for  the  superintendent to produce the annual consumer guide, INCLUDING
THE MENTAL HEALTH PARITY REPORT.   In compiling the  guide,  the  super-
intendent  shall  make  every  effort  to ensure that the information is
presented in a clear, understandable fashion which  facilitates  compar-
isons  among  individual  insurers  and  entities, and in a format which
lends itself to the  widest  possible  distribution  to  consumers.  The
superintendent  shall  either  include  the  information from the annual
consumer guide in the consumer shopping guide required by subsection (a)
of section four thousand three hundred twenty-three of this  chapter  or
combine the two guides as long as consumers in the individual market are
provided with the information required by subsection (a) of section four
thousand three hundred twenty-three of this chapter.
§  5.  This  act  shall take effect on the sixtieth day after it shall
have become a law, provided, however, effective immediately, the  amend-
A3694A - Details
A3694A - Summary
A3694A - Bill Text download pdf
3694--A
tee on  Insurance  --  committee  discharged,  bill  amended,  ordered
AN  ACT  to  amend  the  insurance  law, in relation to establishing the
mental health and substance use disorder parity report act
the "mental health and substance use disorder parity report act".
(a) The superintendent shall annually publish on or  before  September
guide  to  insurers providing managed care products, individual accident
and health insurance or group or blanket accident and  health  insurance
and  entities  licensed  pursuant  to  article  forty-four of the public
health law providing comprehensive health service plans which  includes,
in  detail, a ranking from best to worst based upon each company's claim
using criteria available to  the  department,  adjusted  for  volume  of
coverage  provided.  Such ranking shall also take into consideration the
corresponding total number or percentage of  claims  denied  which  were
reversed  or  compromised  after  intervention by the department and the
department of health, consumer complaints  to  the  department  and  the
department  of  health, violations of section three thousand two hundred
twenty-four-a of this chapter  and  other  pertinent  data  which  would
permit  the department to objectively determine a company's performance.
The department in publishing  such  consumer  guide  shall  publish  one
state-wide  guide  or no more than five regional guides so as to facili-
market area. Such rankings shall be printed in a format which ranks  all
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A. 3694--A                          2
health  insurers  and  all entities certified pursuant to article forty-
four of the public health law in one combined list. THE  CONSUMER  GUIDE
ON  OR BEFORE SEPTEMBER FIRST, TWO THOUSAND EIGHTEEN AND ANNUALLY THERE-
AFTER,  SHALL INCLUDE A MENTAL HEALTH PARITY REPORT AND A SUBSTANCE USES
DISORDER PARITY REPORT BASED UPON EACH COMPANY'S COMPLIANCE WITH  MENTAL
HEALTH  PARITY  AND  SUBSTANCE  USE  DISORDER  PARITY LAWS BASED ON EACH
COMPANY'S RECORD DURING  THE  PRECEDING  CALENDAR  YEAR  USING  CRITERIA
AVAILABLE  TO THE DEPARTMENT, INCLUDING, BUT NOT LIMITED TO, INFORMATION
REQUIRED BY THIS SUBSECTION AND SUBSECTIONS (B), (C)  AND  (D)  OF  THIS
SECTION.  IN  ADDITION, NOTWITHSTANDING SUCH REQUIREMENTS AND ANY LAW TO
THE CONTRARY, THE DATA TO BE INCLUDED IN THE MENTAL HEALTH PARITY REPORT
AND THE SUBSTANCE USE DISORDER PARITY REPORT AND COLLECTED BY THE SUPER-
INTENDENT AND THE COMMISSIONER OF HEALTH FROM INSURERS AND HEALTH PLANS,
FOR SUCH PURPOSES SHALL INCLUDE:
(1) ANNUAL MENTAL HEALTH PARITY  AND  SUBSTANCE  USE  DISORDER  PARITY
COMPLIANCE  REPORTS  FROM  EACH INSURER AND HEALTH PLAN OUTLINING HOW IT
COMPLIES WITH TIMOTHY'S LAW,  THE  INSURANCE  LAW  PROVISIONS  REGARDING
SUBSTANCE  USE  DISORDER AND EATING DISORDERS AND THE PAUL WELLSTONE AND
PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF TWO THOU-
SAND EIGHT;
(2) RATES OF UTILIZATION REVIEW FOR MENTAL HEALTH  AND  SUBSTANCE  USE
DISORDER  CLAIMS  AS  COMPARED TO MEDICAL AND SURGICAL CLAIMS, INCLUDING
RATES OF APPROVAL AND DENIAL, CATEGORIZED BY BENEFITS PROVIDED UNDER THE
FOLLOWING CLASSIFICATIONS, AS REQUIRED UNDER 45  C.F.R.  §  146.136,  29
C.F.R.  §  2590.712  AND  26  C.F.R. § 54.9812-1.: INPATIENT IN-NETWORK,
INPATIENT OUT-OF-NETWORK, OUTPATIENT IN-NETWORK, OUTPATIENT  OUT-OF-NET-
WORK, EMERGENCY CARE, AND PRESCRIPTION DRUGS;
(3)  THE  NUMBER  OF  PRIOR  OR  CONCURRENT AUTHORIZATION REQUESTS FOR
MENTAL HEALTH SERVICES AND FOR SUBSTANCE USE DISORDER SERVICES  AND  THE
NUMBER  OF  DENIALS FOR SUCH REQUESTS, COMPARED WITH THE NUMBER OF PRIOR
OR CONCURRENT AUTHORIZATION REQUESTS FOR MEDICAL AND  SURGICAL  SERVICES
AND  THE  NUMBER  OF  DENIALS FOR SUCH REQUESTS, CATEGORIZED BY THE SAME
CLASSIFICATIONS IDENTIFIED IN PARAGRAPH TWO  OF  THIS  SUBSECTION  WHICH
BENEFITS AND SUBSTANCE USE DISORDER BENEFITS;
(4) THE NUMBER OF  PRIOR  OR  CONCURRENT  AUTHORIZATION  REQUESTS  FOR
MENTAL  HEALTH SERVICES AND SUBSTANCE USE DISORDER SERVICES THAT WENT TO
CLINICAL PEER REVIEW AS A RESULT OF A DISAGREEMENT BETWEEN  THE  SERVICE
PROVIDER  AND  THE  INSURER  OR  HEALTH PLAN AND THE NUMBER THAT WENT TO
CLINICAL PEER REVIEW FOR MEDICAL AND SURGICAL  SERVICES  CATEGORIZED  IN
THE SAME MANNER AS PROVIDED IN PARAGRAPH TWO OF THIS SUBSECTION;
(5) THE LIST OF SERVICES THAT HAVE A PRIOR OR CONCURRENT AUTHORIZATION
REQUIREMENT  BASED ON A NUMERICAL THRESHOLD DEFINED BY A SPECIFIC NUMBER
OF VISITS OR DAYS OF CARE FOR  MENTAL  HEALTH  SERVICES,  SUBSTANCE  USE
DISORDER  SERVICES  AND MEDICAL AND SURGICAL SERVICES AND IDENTIFICATION
OF THE THRESHOLD REQUIREMENTS;
(6) THE LIST OF COVERED MEDICATIONS FOR THE TREATMENT OF  A  SUBSTANCE
USE DISORDER ON THE PRESCRIPTION DRUG LIST OF THE INSURER OR HEALTH PLAN
INCLUDING  TIER  PLACEMENT,  AUTHORIZATION  REQUIREMENTS  AND  ALL OTHER
UTILIZATION MANAGEMENT REQUIREMENTS;
(7) THE  PERCENTAGE  OF  CLAIMS  PAID  FOR  IN-NETWORK  MENTAL  HEALTH
SERVICES  AND  FOR SUBSTANCE USE DISORDER SERVICES AND THE PERCENTAGE OF
CLAIMS PAID FOR IN-NETWORK MEDICAL AND SURGICAL SERVICES;
(8) THE PERCENTAGE OF CLAIMS PAID  FOR  OUT-OF-NETWORK  MENTAL  HEALTH
SERVICES  AND SUBSTANCE USE DISORDER SERVICES COMPARED WITH THE PERCENT-
A. 3694--A                          3
AGE OF CLAIMS PAID FOR OTHER TYPES OF OUT-OF-NETWORK MEDICAL AND  SURGI-
CAL SERVICES;
(9)  THE MEDICAL NECESSITY CRITERIA THE INSURER OR HEALTH PLAN USES TO
MAKE PRIOR AUTHORIZATION  OR  CONTINUING  CARE  AND  DISCHARGE  DETERMI-
NATIONS,  WHICH  IN CONJUNCTION MUST BE CONSPICUOUSLY POSTED FOR POLICY-
HOLDERS AND PROVIDERS TO BE ABLE TO REVIEW WITHOUT MAKING A  REQUEST  ON
THE INSURER'S OR THE HEALTH PLAN'S WEBSITE AND BE MADE AVAILABLE IN HARD
COPY UPON REQUEST;
(10)  THE NUMBER OF BEHAVIORAL HEALTH ADVOCATES, PURSUANT TO AN AGREE-
MENT WITH THE OFFICE OF THE ATTORNEY GENERAL IF APPLICABLE, OR STAFF  ON
HAND  TO  ASSIST  POLICYHOLDERS  WITH  BENEFITS  FOR  MENTAL  HEALTH  OR
(11) THE NETWORK ADEQUACY OF INSURERS AND HEALTH PLANS, WHICH IN ADDI-
HUNDRED FORTY-ONE OF THIS CHAPTER AND SUBSECTION (C)  OF  THIS  SECTION,
SHALL  CONSIST OF VERIFYING THE MENTAL HEALTH AND SUBSTANCE USE DISORDER
PROVIDERS LISTED IN AN INSURER'S OR HEALTH PLAN'S PROVIDER DIRECTORY  AS
IN NETWORK. SUCH VERIFICATION SHALL BE PROVIDED BY THE INSURER OR HEALTH
PLAN, ON A SEMI-ANNUAL BASIS, BY PROVIDING ITS LIST OF IN-NETWORK MENTAL
HEALTH  AND  SUBSTANCE  USE  DISORDER PROVIDERS AND THE NUMBER OF CLAIMS
EACH PROVIDER HAS SUBMITTED WITHIN THE PAST SIX MONTHS. THE  LIST  SHALL
INCLUDE  THE  NAME,  ADDRESS  AND  TELEPHONE NUMBER OF ALL PARTICIPATING
IN-NETWORK PROVIDERS.  FOR PROVIDERS THAT HAVE HAD NO CLAIMS IN THE PAST
SIX MONTHS, THE INSURER OR HEALTH PLAN MUST PROVIDE AN ATTESTATION  THAT
SUCH  PROVIDER  IS  STILL  PART  OF THE NETWORK AND THAT THE PROVIDER IS
ACCEPTING NEW PATIENTS. FOR QUALIFIED HEALTH PLANS OFFERED ON  NEW  YORK
STATE  OF  HEALTH,  THE  DEPARTMENT  OF  HEALTH SHALL REVIEW THE NETWORK
ADEQUACY TO ENSURE IT IS CONSISTENT  WITH  45  CFR  §  156.230  AND  THE
DEPARTMENT  OF HEALTH'S MANAGED CARE NETWORK ADEQUACY STANDARD INCLUDING
VERIFICATION OF THE MENTAL HEALTH AND SUBSTANCE USE  DISORDER  PROVIDERS
LISTED  IN  A  QUALIFIED HEALTH PLAN'S PROVIDER DIRECTORY AS IN-NETWORK.
SUCH VERIFICATION SHALL BE PROVIDED BY A QUALIFIED  HEALTH  PLAN,  ON  A
SEMI-ANNUAL BASIS, BY PROVIDING ITS LIST OF IN-NETWORK MENTAL HEALTH AND
SUBSTANCE  USE DISORDER PROVIDERS AND THE NUMBER OF CLAIMS EACH PROVIDER
HAS SUBMITTED WITHIN THE PAST SIX MONTHS. THE  LIST  SHALL  INCLUDE  THE
NAME,  ADDRESS  AND TELEPHONE NUMBER OF ALL PARTICIPATING PROVIDERS. FOR
PROVIDERS THAT HAVE NO CLAIMS IN THE  PAST  SIX  MONTHS,  THE  QUALIFIED
HEALTH PLAN MUST PROVIDE AN ATTESTATION THAT SUCH PROVIDER IS STILL PART
OF THE NETWORK AND THAT THE PROVIDER IS ACCEPTING NEW PATIENTS;
(12)  THE NUMBER OF MENTAL HEALTH AND SUBSTANCE USE DISORDER PROVIDERS
WHO HAVE LEFT OR BEEN REMOVED FROM THE PROVIDER NETWORK IN THE PAST  SIX
MONTHS AND THE REASON THAT THEY HAVE LEFT OR BEEN REMOVED; AND
(13)  ANY  OTHER DATA OR METRIC THE SUPERINTENDENT OR THE COMMISSIONER
OF HEALTH DEEMS IS NECESSARY TO MEASURE COMPLIANCE  WITH  MENTAL  HEALTH
PARITY AND SUBSTANCE USE DISORDER PARITY.
§  3.  Paragraph  2  of subsection (c) of section 210 of the insurance
law, as added by chapter 579 of the laws of 1998, is amended to read  as
ing  providers,  provided  however,  that  such percentage shall exclude
voluntary terminations due to physician retirement, relocation or  other
similar  reasons,  AND  THE  PERCENTAGE  OF MENTAL HEALTH PROFESSIONALS,
DEFINED AS PHYSICIANS WHO ARE LICENSED PURSUANT TO ARTICLE  ONE  HUNDRED
THIRTY-ONE  OF THE EDUCATION LAW WHO ARE DIPLOMATS OF THE AMERICAN BOARD
OF PSYCHIATRY AND NEUROLOGY OR ARE ELIGIBLE  TO  BE  CERTIFIED  BY  THAT
BOARD,  OR  ARE CERTIFIED BY THE AMERICAN OSTEOPATHIC BOARD OF NEUROLOGY
A. 3694--A                          4
AND PSYCHIATRY OR ARE ELIGIBLE TO BE CERTIFIED BY THAT BOARD,  A  SOCIAL
TION  LAW  OR  A  PSYCHOLOGIST  LICENSED PURSUANT TO ARTICLE ONE HUNDRED
THE MENTAL HEALTH PARITY REPORT AND THE SUBSTANCE  USE  DISORDER  PARITY
REPORT.    In  compiling  the guide, the superintendent shall make every
effort to ensure that the information is presented in  a  clear,  under-
standable  fashion which facilitates comparisons among individual insur-
ers and entities, and in a format  which  lends  itself  to  the  widest
possible  distribution  to  consumers.  The  superintendent shall either
include the information from the annual consumer guide in  the  consumer
shopping guide required by subsection (a) of section four thousand three
hundred  twenty-three  of this chapter or combine the two guides as long
as consumers in the individual market are provided with the  information
required  by subsection (a) of section four thousand three hundred twen-
ty-three of this chapter.
§ 5. This act shall take effect on the sixtieth  day  after  it  shall
have  become a law, provided, however, effective immediately, the amend-
View More (156 Lines)
A3694B - Details
A3694B - Summary
A3694B - Bill Text download pdf
3694--B
to the Committee on Insurance in accordance with Assembly Rule 3, sec.
2 -- committee discharged, bill amended, ordered reprinted as  amended
LBD02509-10-8
A. 3694--B                          2
ON  OR BEFORE SEPTEMBER FIRST, TWO THOUSAND NINETEEN AND ANNUALLY THERE-
AFTER, SHALL INCLUDE A MENTAL HEALTH PARITY REPORT AND A SUBSTANCE  USES
DISORDER  PARITY REPORT BASED UPON EACH COMPANY'S COMPLIANCE WITH MENTAL
HEALTH PARITY AND SUBSTANCE USE  DISORDER  PARITY  LAWS  BASED  ON  EACH
COMPANY'S  RECORD  DURING  THE  PRECEDING  CALENDAR  YEAR USING CRITERIA
AVAILABLE TO THE DEPARTMENT, INCLUDING, BUT NOT LIMITED TO,  INFORMATION
REQUIRED  BY  THIS  SUBSECTION  AND SUBSECTIONS (B), (C) AND (D) OF THIS
SECTION. IN ADDITION, NOTWITHSTANDING SUCH REQUIREMENTS AND ANY  LAW  TO
(1)  ANNUAL  MENTAL  HEALTH  PARITY  AND SUBSTANCE USE DISORDER PARITY
COMPLIANCE REPORTS FROM EACH INSURER AND HEALTH PLAN  OUTLINING  HOW  IT
COMPLIES  WITH  TIMOTHY'S  LAW,  THE  INSURANCE LAW PROVISIONS REGARDING
SUBSTANCE USE DISORDER AND EATING DISORDERS AND THE PAUL  WELLSTONE  AND
(2)  RATES  OF  UTILIZATION REVIEW FOR MENTAL HEALTH AND SUBSTANCE USE
DISORDER CLAIMS AS COMPARED TO MEDICAL AND  SURGICAL  CLAIMS,  INCLUDING
FOLLOWING  CLASSIFICATIONS,  AS  REQUIRED  UNDER 45 C.F.R. § 146.136, 29
C.F.R. § 2590.712 AND 26  C.F.R.  §  54.9812-1.:  INPATIENT  IN-NETWORK,
INPATIENT  OUT-OF-NETWORK, OUTPATIENT IN-NETWORK, OUTPATIENT OUT-OF-NET-
(3) THE NUMBER OF  PRIOR  OR  CONCURRENT  AUTHORIZATION  REQUESTS  FOR
MENTAL  HEALTH  SERVICES AND FOR SUBSTANCE USE DISORDER SERVICES AND THE
NUMBER OF DENIALS FOR SUCH REQUESTS, COMPARED WITH THE NUMBER  OF  PRIOR
OR  CONCURRENT  AUTHORIZATION REQUESTS FOR MEDICAL AND SURGICAL SERVICES
AND THE NUMBER OF DENIALS FOR SUCH REQUESTS,  CATEGORIZED  BY  THE  SAME
CLASSIFICATIONS  IDENTIFIED  IN  PARAGRAPH  TWO OF THIS SUBSECTION WHICH
RATES OF APPEALS UPHELD AND OVERTURNED, SPECIFICALLY FOR  MENTAL  HEALTH
(4)  THE  NUMBER  OF  PRIOR  OR  CONCURRENT AUTHORIZATION REQUESTS FOR
MENTAL HEALTH SERVICES AND SUBSTANCE USE DISORDER SERVICES THAT WENT  TO
CLINICAL  PEER  REVIEW AS A RESULT OF A DISAGREEMENT BETWEEN THE SERVICE
PROVIDER AND THE INSURER OR HEALTH PLAN AND  THE  NUMBER  THAT  WENT  TO
CLINICAL  PEER  REVIEW  FOR MEDICAL AND SURGICAL SERVICES CATEGORIZED IN
REQUIREMENT BASED ON A NUMERICAL THRESHOLD DEFINED BY A SPECIFIC  NUMBER
OF  VISITS  OR  DAYS  OF  CARE FOR MENTAL HEALTH SERVICES, SUBSTANCE USE
DISORDER SERVICES AND MEDICAL AND SURGICAL SERVICES  AND  IDENTIFICATION
(6)  THE  LIST OF COVERED MEDICATIONS FOR THE TREATMENT OF A SUBSTANCE
INCLUDING TIER  PLACEMENT,  AUTHORIZATION  REQUIREMENTS  AND  ALL  OTHER
A. 3694--B                          3
(7)  THE  PERCENTAGE  OF  CLAIMS  PAID  FOR  IN-NETWORK  MENTAL HEALTH
SERVICES AND FOR SUBSTANCE USE DISORDER SERVICES AND THE  PERCENTAGE  OF
(8)  THE  PERCENTAGE  OF  CLAIMS PAID FOR OUT-OF-NETWORK MENTAL HEALTH
SERVICES AND SUBSTANCE USE DISORDER SERVICES COMPARED WITH THE  PERCENT-
AGE  OF CLAIMS PAID FOR OTHER TYPES OF OUT-OF-NETWORK MEDICAL AND SURGI-
(9) THE MEDICAL NECESSITY CRITERIA THE INSURER OR HEALTH PLAN USES  TO
MAKE  PRIOR  AUTHORIZATION  OR  CONTINUING  CARE  AND DISCHARGE DETERMI-
NATIONS, WHICH IN CONJUNCTION MUST BE CONSPICUOUSLY POSTED  FOR  POLICY-
HOLDERS  AND  PROVIDERS TO BE ABLE TO REVIEW WITHOUT MAKING A REQUEST ON
(10) THE NUMBER OF BEHAVIORAL HEALTH ADVOCATES, PURSUANT TO AN  AGREE-
MENT  WITH THE OFFICE OF THE ATTORNEY GENERAL IF APPLICABLE, OR STAFF ON
SHALL CONSIST OF VERIFYING THE MENTAL HEALTH AND SUBSTANCE USE  DISORDER
PROVIDERS  LISTED IN AN INSURER'S OR HEALTH PLAN'S PROVIDER DIRECTORY AS
HEALTH AND SUBSTANCE USE DISORDER PROVIDERS AND  THE  NUMBER  OF  CLAIMS
EACH  PROVIDER  HAS SUBMITTED WITHIN THE PAST SIX MONTHS. THE LIST SHALL
INCLUDE THE NAME, ADDRESS AND  TELEPHONE  NUMBER  OF  ALL  PARTICIPATING
SIX  MONTHS, THE INSURER OR HEALTH PLAN MUST PROVIDE AN ATTESTATION THAT
SUCH PROVIDER IS STILL PART OF THE NETWORK  AND  THAT  THE  PROVIDER  IS
ACCEPTING  NEW  PATIENTS. FOR QUALIFIED HEALTH PLANS OFFERED ON NEW YORK
STATE OF HEALTH, THE DEPARTMENT  OF  HEALTH  SHALL  REVIEW  THE  NETWORK
ADEQUACY  TO  ENSURE  IT  IS  CONSISTENT  WITH  45 CFR § 156.230 AND THE
DEPARTMENT OF HEALTH'S MANAGED CARE NETWORK ADEQUACY STANDARD  INCLUDING
VERIFICATION  OF  THE MENTAL HEALTH AND SUBSTANCE USE DISORDER PROVIDERS
LISTED IN A QUALIFIED HEALTH PLAN'S PROVIDER  DIRECTORY  AS  IN-NETWORK.
SUCH  VERIFICATION  SHALL  BE  PROVIDED BY A QUALIFIED HEALTH PLAN, ON A
SUBSTANCE USE DISORDER PROVIDERS AND THE NUMBER OF CLAIMS EACH  PROVIDER
HAS  SUBMITTED  WITHIN  THE  PAST SIX MONTHS. THE LIST SHALL INCLUDE THE
NAME, ADDRESS AND TELEPHONE NUMBER OF ALL PARTICIPATING  PROVIDERS.  FOR
PROVIDERS  THAT  HAVE  NO  CLAIMS  IN THE PAST SIX MONTHS, THE QUALIFIED
(12) THE NUMBER OF MENTAL HEALTH AND SUBSTANCE USE DISORDER  PROVIDERS
WHO  HAVE LEFT OR BEEN REMOVED FROM THE PROVIDER NETWORK IN THE PAST SIX
(13) ANY OTHER DATA OR METRIC THE SUPERINTENDENT OR  THE  COMMISSIONER
OF  HEALTH  DEEMS  IS NECESSARY TO MEASURE COMPLIANCE WITH MENTAL HEALTH
A. 3694--B                          4
A3694C (ACTIVE) - Details
A3694C (ACTIVE) - Summary
A3694C (ACTIVE) - Bill Text download pdf
3694--C
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,
committee  --  recommitted to the Committee on Insurance in accordance
§ 2. Section 210 of the insurance law  is  amended  by  adding  a  new
subsection (c-1) to read as follows:
(C-1)  BEGINNING  SEPTEMBER  FIRST, TWO THOUSAND NINETEEN AND ANNUALLY
THEREAFTER, THE SUPERINTENDENT SHALL INCLUDE  IN  SUCH  GUIDE  A  MENTAL
HEALTH AND SUBSTANCE USE DISORDER PARITY REPORT DETAILING EACH COMPANY'S
COMPLIANCE WITH FEDERAL AND STATE MENTAL HEALTH AND SUBSTANCE USE DISOR-
DER  PARITY  LAWS  BASED  ON  EACH COMPANY'S RECORD DURING THE PRECEDING
CALENDAR YEAR.  THE SUPERINTENDENT SHALL INCLUDE  IN  SUCH  REPORT,  AND
EACH  COMPANY  SHALL  PROVIDE  TO  THE  SUPERINTENDENT  THE  INFORMATION
REQUIRED FOR SUCH GUIDE IN A TIMELY FASHION, THE FOLLOWING INFORMATION:
(1) RATES OF UTILIZATION REVIEW FOR MENTAL HEALTH  AND  SUBSTANCE  USE
FOLLOWING CLASSIFICATIONS:  INPATIENT IN-NETWORK, INPATIENT  OUT-OF-NET-
WORK,  OUTPATIENT IN-NETWORK, OUTPATIENT OUT-OF-NETWORK, EMERGENCY CARE,
AND PRESCRIPTION DRUGS;
LBD02509-11-8
A. 3694--C                          2
(2) THE NUMBER OF  PRIOR  OR  CONCURRENT  AUTHORIZATION  REQUESTS  FOR
CLASSIFICATIONS IDENTIFIED IN PARAGRAPH ONE OF THIS SUBSECTION;
(3) THE RATES OF APPEALS  OF  ADVERSE  DETERMINATIONS,  INCLUDING  THE
RATES OF ADVERSE DETERMINATIONS UPHELD AND OVERTURNED, FOR MENTAL HEALTH
CLAIMS  AND  SUBSTANCE  USE  DISORDER  CLAIMS COMPARED WITH THE RATES OF
APPEALS OF ADVERSE DETERMINATIONS, INCLUDING THE RATES OF ADVERSE DETER-
MINATIONS UPHELD AND OVERTURNED, FOR MEDICAL AND SURGICAL CLAIMS;
(4) THE  PERCENTAGE  OF  CLAIMS  PAID  FOR  IN-NETWORK  MENTAL  HEALTH
SERVICES  AND  FOR  SUBSTANCE  USE  DISORDER  SERVICES COMPARED WITH THE
PERCENTAGE OF CLAIMS PAID FOR IN-NETWORK MEDICAL AND  SURGICAL  SERVICES
AND  THE  PERCENTAGE  OF  CLAIMS  PAID  FOR OUT-OF-NETWORK MENTAL HEALTH
AGE OF CLAIMS PAID FOR OUT-OF-NETWORK MEDICAL AND SURGICAL SERVICES;
(5)  THE  NUMBER OF BEHAVIORAL HEALTH ADVOCATES, PURSUANT TO AN AGREE-
MENT WITH THE OFFICE OF THE ATTORNEY GENERAL  IF  APPLICABLE,  OR  STAFF
AVAILABLE  TO  ASSIST  POLICYHOLDERS  WITH  MENTAL  HEALTH  BENEFITS AND
SUBSTANCE USE DISORDER BENEFITS;
(6) A COMPARISON OF THE COST SHARING REQUIREMENTS  INCLUDING  BUT  NOT
LIMITED  TO CO-PAYS AND COINSURANCE, AND THE BENEFIT LIMITATIONS INCLUD-
ING LIMITATIONS ON THE SCOPE AND DURATION OF COVERAGE, FOR  MEDICAL  AND
SURGICAL SERVICES, AND MENTAL HEALTH SERVICES AND SUBSTANCE USE DISORDER
(7) THE NUMBER BY TYPE OF PROVIDERS LICENSED TO PRACTICE IN THIS STATE
THAT  PROVIDE  SERVICES FOR THE TREATMENT AND DIAGNOSIS OF SUBSTANCE USE
DISORDER WHO ARE  IN-NETWORK,  AND  THE  NUMBER  BY  TYPE  OF  PROVIDERS
LICENSED TO PRACTICE IN THIS STATE THAT PROVIDE SERVICES FOR THE DIAGNO-
SIS  AND  TREATMENT  OF  MENTAL,  NERVOUS  OR  EMOTIONAL  DISORDERS  AND
AILMENTS, HOWEVER DEFINED IN A COMPANY'S POLICY, WHO ARE IN-NETWORK;
(8) THE PERCENTAGE OF PROVIDERS OF  SERVICES  FOR  THE  TREATMENT  AND
DIAGNOSIS  OF  SUBSTANCE USE DISORDER WHO REMAINED PARTICIPATING PROVID-
ERS, AND THE PERCENTAGE OF PROVIDERS OF SERVICES FOR THE  DIAGNOSIS  AND
TREATMENT OF MENTAL, NERVOUS OR EMOTIONAL DISORDERS AND AILMENTS, HOWEV-
ER  DEFINED IN A COMPANY'S POLICY, WHO REMAINED PARTICIPATING PROVIDERS;
(9) ANY OTHER DATA OR METRIC THE  SUPERINTENDENT  DEEMS  NECESSARY  TO
MEASURE  COMPLIANCE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDER PARITY
INCLUDING, BUT NOT LIMITED TO AN EVALUATION AND ASSESSMENT OF:  (I)  THE
ADEQUACY   OF  THE  COMPANY'S  IN-NETWORK  MENTAL  HEALTH  SERVICES  AND
SUBSTANCE USE DISORDER PROVIDER PANELS PURSUANT  TO  PROVISIONS  OF  THE
INSURANCE  LAW  AND PUBLIC HEALTH LAW; AND (II) THE COMPANY'S REIMBURSE-
MENT FOR  IN-NETWORK  AND  OUT-OF-NETWORK  MENTAL  HEALTH  SERVICES  AND
SUBSTANCE  USE  DISORDER  SERVICES  AS COMPARED TO THE REIMBURSEMENT FOR
IN-NETWORK AND OUT-OF-NETWORK MEDICAL AND SURGICAL SERVICES.
§ 3. Subsection (d) of section 210 of the insurance law, as  added  by
THE MENTAL HEALTH AND SUBSTANCE USE DISORDER PARITY REPORT.  In  compil-
ing the guide, the superintendent shall make every effort to ensure that
A. 3694--C                          3
the  information  is  presented in a clear, understandable fashion which
facilitates comparisons among individual insurers and entities, and in a
format which lends itself to the widest possible distribution to consum-
ers.  The  superintendent  shall either include the information from the
annual consumer  guide  in  the  consumer  shopping  guide  required  by
subsection  (a)  of  section four thousand three hundred twenty-three of
this chapter or combine the two guides as long as consumers in the indi-
vidual market are provided with the information required  by  subsection
(a) of section four thousand three hundred twenty-three of this chapter.