Bill Text: NY S05300 | 2023-2024 | General Assembly | Introduced

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Bill Title: Relates to behavioral health parity; requires facilities to perform daily clinical review of a patient and consult periodically with the insurer regarding the patient's progress, course of treatment, and discharge plan; requires insurers to actively participate in facility-initiated periodic consultations prior to the patient's discharge; makes related provisions (Part A); provides that no policy shall require prior authorization for an initial or renewal prescription for drugs for the detoxification or maintenance of a substance use disorder; makes related provisions (Part B).

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2024-01-03 - REFERRED TO INSURANCE [S05300 Detail]

Download: New_York-2023-S05300-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          5300

                               2023-2024 Regular Sessions

                    IN SENATE

                                      March 1, 2023
                                       ___________

        Introduced by Sen. FERNANDEZ -- read twice and ordered printed, and when
          printed to be committed to the Committee on Insurance

        AN  ACT  to amend the insurance law, in relation to providing behavioral
          health parity (Part A); and to amend the insurance law, in relation to
          the authorization for certain drugs for the detoxification or  mainte-
          nance of a substance use disorder (Part B)

          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:

     1    Section 1. This act enacts into law components  of  legislation  which
     2  are  necessary  to  effectuate  provisions relating to mental health and
     3  substance use disorder parity.  Each component is wholly contained with-
     4  in a Part identified as Parts A through B. The effective date  for  each
     5  particular provision contained within such Part is set forth in the last
     6  section  of  such  Part. Any provision in any section contained within a
     7  Part, including  the  effective date of the Part, which makes  reference
     8  to  a  section "of this act", when used in connection with that  partic-
     9  ular component, shall  be  deemed  to mean and refer to the  correspond-
    10  ing  section of the Part in which it is found. Section three of this act
    11  sets forth the general effective date of this act.

    12                                   PART A

    13    Section 1. Subparagraph (D) of  paragraph  30  of  subsection  (i)  of
    14  section  3216 of the insurance law, as amended by section 5 of subpart A
    15  of part BB of chapter 57 of the laws of 2019,  is  amended  to  read  as
    16  follows:
    17    (D) This subparagraph shall apply to facilities in this state that are
    18  licensed, certified or otherwise authorized by the office of [alcoholism
    19  and  substance  abuse services] addiction services and supports that are
    20  participating in the insurer's provider network. Coverage provided under
    21  this paragraph  shall  not  be  subject  to  preauthorization.  Coverage

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03088-01-3
        S. 5300                             2

     1  provided  under  this  paragraph shall also not be subject to concurrent
     2  utilization review during the first twenty-eight days of  the  inpatient
     3  admission  provided  that  the facility notifies the insurer of both the
     4  admission and the initial treatment plan within two business days of the
     5  admission  on a standardized form developed by the department in consul-
     6  tation with the  department  of  health  and  the  office  of  addiction
     7  services  and supports. The facility shall perform daily clinical review
     8  of the patient[, including periodic] and consult periodically  with  the
     9  insurer  regarding  the  patient's  progress,  course  of treatment, and
    10  discharge plan. Periodic consultation with the insurer [at or just prior
    11  to] shall occur no later than the fourteenth day of treatment [to ensure
    12  that the facility is using the evidence-based and peer reviewed clinical
    13  review tool utilized by the insurer which is designated by the office of
    14  alcoholism and substance abuse services and appropriate to  the  age  of
    15  the  patient, to ensure that the inpatient treatment is medically neces-
    16  sary for the patient]. Prior to discharge, the  facility  shall  provide
    17  the  patient  and  the insurer with a written discharge plan which shall
    18  describe arrangements for additional services needed following discharge
    19  from the inpatient facility as determined using the  evidence-based  and
    20  peer-reviewed  clinical  review  tool  utilized  by the insurer which is
    21  designated by the office of [alcoholism and  substance  abuse  services]
    22  addiction  services and supports. Prior to discharge, the facility shall
    23  indicate to the insurer whether services included in the discharge  plan
    24  are  secured  or  determined  to be reasonably available. [Any] Insurers
    25  shall actively participate in facility-initiated periodic  consultations
    26  prior  to  the patient's discharge and except where the insurer fails to
    27  do so, any utilization review of treatment provided under this  subpara-
    28  graph  may  include  a review of all services provided during such inpa-
    29  tient treatment, including all services provided during the first  twen-
    30  ty-eight  days  of  such  inpatient  treatment.  Provided,  however, the
    31  insurer shall be required to process claims for the  provision  of  such
    32  services  within the timeframes established in subsection (a) of section
    33  three thousand two hundred twenty-four-a of this article and shall  only
    34  deny  coverage for any portion of the initial twenty-eight day inpatient
    35  treatment on the basis that such treatment was not  medically  necessary
    36  if  such inpatient treatment was contrary to the evidence-based and peer
    37  reviewed clinical review tool utilized by the insurer  which  is  desig-
    38  nated  by  the  office  of  [alcoholism  and  substance  abuse services]
    39  addiction services and supports. An insured shall not have any financial
    40  obligation to the facility for any  treatment  under  this  subparagraph
    41  other  than any copayment, coinsurance, or deductible otherwise required
    42  under the policy.
    43    § 2. Subparagraph (E) of paragraph 31 of  subsection  (i)  of  section
    44  3216  of the insurance law, as amended by section 6 of subpart A of part
    45  BB of chapter 57 of the laws of 2019, is amended to read as follows:
    46    (E) This subparagraph shall apply to facilities in this state that are
    47  licensed, certified or otherwise authorized by the office of [alcoholism
    48  and substance abuse services] addiction services and  supports  for  the
    49  provision of outpatient, intensive outpatient, outpatient rehabilitation
    50  and  opioid  treatment  that are participating in the insurer's provider
    51  network. Coverage provided under this paragraph shall not be subject  to
    52  preauthorization.  Coverage  provided  under this paragraph shall not be
    53  subject to concurrent review for the  first  four  weeks  of  continuous
    54  treatment,  not  to  exceed  twenty-eight  visits, provided the facility
    55  notifies the insurer of both the start  of  treatment  and  the  initial
    56  treatment plan within two business days on a standardized form developed
        S. 5300                             3

     1  by  the department in consultation with the department of health and the
     2  office of addiction services and supports. The  facility  shall  perform
     3  clinical  assessment  of the patient at each visit[, including periodic]
     4  and  consult  periodically  with  the  insurer  regarding  the patient's
     5  progress, course of treatment, and discharge plan. Periodic consultation
     6  with the insurer [at or just prior to] shall occur  no  later  than  the
     7  fourteenth  day  of  treatment [to ensure that the facility is using the
     8  evidence-based and peer reviewed clinical review tool  utilized  by  the
     9  insurer  which  is  designated by the office of alcoholism and substance
    10  abuse services and appropriate to the age of the patient, to ensure that
    11  the outpatient treatment is medically necessary for the patient].  [Any]
    12  Insurers  shall  actively  participate  in  facility-initiated  periodic
    13  consultations prior to the patient's  discharge  and  except  where  the
    14  insurer fails to do so, any utilization review of the treatment provided
    15  under  this  subparagraph  may include a review of all services provided
    16  during such outpatient treatment, including all services provided during
    17  the first four weeks of continuous treatment, not to exceed twenty-eight
    18  visits, of such outpatient treatment.  Provided,  however,  the  insurer
    19  shall  only  deny  coverage for any portion of the initial four weeks of
    20  continuous treatment, not to exceed twenty-eight visits, for  outpatient
    21  treatment  on  the basis that such treatment was not medically necessary
    22  if such outpatient treatment was contrary to the evidence-based and peer
    23  reviewed clinical review tool utilized by the insurer  which  is  desig-
    24  nated  by  the  office  of  [alcoholism  and  substance  abuse services]
    25  addiction services and supports.  An insured shall not have  any  finan-
    26  cial  obligation  to  the facility for any treatment under this subpara-
    27  graph other than any copayment,  coinsurance,  or  deductible  otherwise
    28  required under the policy.
    29    §  3.  Subparagraph  (G)  of paragraph 35 of subsection (i) of section
    30  3216 of the insurance law, as added by section 8 of subpart A of part BB
    31  of chapter 57 of the laws of 2019, is amended to read as follows:
    32    (G) This subparagraph shall apply to hospitals in this state that  are
    33  licensed,  certified  or  otherwise  authorized  by the office of mental
    34  health that are participating in the insurer's provider  network.  Where
    35  the  policy  provides coverage for inpatient hospital care, benefits for
    36  inpatient hospital care in a hospital as defined by subdivision  ten  of
    37  section 1.03 of the mental hygiene law [provided to individuals who have
    38  not  attained  the  age of eighteen] shall not be subject to preauthori-
    39  zation. Coverage provided under this  subparagraph  shall  also  not  be
    40  subject  to concurrent utilization review during the first fourteen days
    41  of the inpatient admission, provided the facility notifies  the  insurer
    42  of both the admission and the initial treatment plan within two business
    43  days of the admission on a standardized form developed by the department
    44  in  consultation  with the department of health and the office of mental
    45  health, performs daily clinical review of the patient, and [participates
    46  in periodic consultation with the insurer to ensure that the facility is
    47  using the evidence-based and  peer  reviewed  clinical  review  criteria
    48  utilized by the insurer which is approved by the office of mental health
    49  and  appropriate to the age of the patient, to ensure that the inpatient
    50  care is medically necessary for the patient] consults periodically  with
    51  the  insurer  regarding the patient's progress, course of treatment, and
    52  discharge plan. [All] Insurers shall actively participate  in  facility-
    53  initiated  periodic  consultations  prior to the patient's discharge and
    54  except where the insurer fails to do so, all  treatment  provided  under
    55  this  subparagraph may be reviewed retrospectively. Where care is denied
    56  retrospectively, an insured shall not have any financial  obligation  to
        S. 5300                             4

     1  the  facility  for  any treatment under this subparagraph other than any
     2  copayment, coinsurance, or deductible otherwise required under the poli-
     3  cy.
     4    § 4. Subparagraph (G) of paragraph 5 of subsection (l) of section 3221
     5  of  the insurance law, as added by section 14 of subpart A of part BB of
     6  chapter 57 of the laws of 2019, is amended to read as follows:
     7    (G) This subparagraph shall apply to hospitals in this state that  are
     8  licensed,  certified  or  otherwise  authorized  by the office of mental
     9  health that are participating in the insurer's provider  network.  Where
    10  the  policy  provides coverage for inpatient hospital care, benefits for
    11  inpatient hospital care in a hospital as defined by subdivision  ten  of
    12  section 1.03 of the mental hygiene law [provided to individuals who have
    13  not  attained  the  age of eighteen] shall not be subject to preauthori-
    14  zation. Coverage provided under this  subparagraph  shall  also  not  be
    15  subject  to concurrent utilization review during the first fourteen days
    16  of the inpatient admission, provided the facility notifies  the  insurer
    17  of both the admission and the initial treatment plan within two business
    18  days of the admission on a standardized form developed by the department
    19  in  consultation  with the department of health and the office of mental
    20  health, performs daily clinical review of the patient, and [participates
    21  in periodic consultation with the insurer to ensure that the facility is
    22  using the evidence-based and  peer  reviewed  clinical  review  criteria
    23  utilized by the insurer which is approved by the office of mental health
    24  and  appropriate to the age of the patient, to ensure that the inpatient
    25  care is medically necessary for the patient] consults periodically  with
    26  the  insurer  regarding the patient's progress, course of treatment, and
    27  discharge plan. [All] Insurers shall actively participate  in  facility-
    28  initiated  periodic  consultations  prior to the patient's discharge and
    29  except where the insurer fails to do so, all  treatment  provided  under
    30  this  subparagraph may be reviewed retrospectively. Where care is denied
    31  retrospectively, an insured shall not have any financial  obligation  to
    32  the  facility  for  any treatment under this subparagraph other than any
    33  copayment, coinsurance, or deductible otherwise required under the poli-
    34  cy.
    35    § 5. Subparagraph (D) of paragraph 6 of subsection (l) of section 3221
    36  of the insurance law, as amended by section 15 of subpart A of  part  BB
    37  of chapter 57 of the laws of 2019, is amended to read as follows:
    38    (D) This subparagraph shall apply to facilities in this state that are
    39  licensed, certified or otherwise authorized by the office of [alcoholism
    40  and  substance  abuse services] addiction services and supports that are
    41  participating in the insurer's provider network. Coverage provided under
    42  this paragraph  shall  not  be  subject  to  preauthorization.  Coverage
    43  provided  under  this  paragraph shall also not be subject to concurrent
    44  utilization review during the first twenty-eight days of  the  inpatient
    45  admission  provided  that  the facility notifies the insurer of both the
    46  admission and the initial treatment plan within two business days of the
    47  admission on a standardized form developed by the department in  consul-
    48  tation  with  the  department  of  health  and  the  office of addiction
    49  services and supports. The facility shall perform daily clinical  review
    50  of  the  patient[, including periodic] and consult periodically with the
    51  insurer regarding the  patient's  progress,  course  of  treatment,  and
    52  discharge plan. Periodic consultation with the insurer [at or just prior
    53  to] shall occur no later than the fourteenth day of treatment [to ensure
    54  that the facility is using the evidence-based and peer reviewed clinical
    55  review tool utilized by the insurer which is designated by the office of
    56  alcoholism  and  substance  abuse services and appropriate to the age of
        S. 5300                             5

     1  the patient, to ensure that the inpatient treatment is medically  neces-
     2  sary  for  the  patient]. Prior to discharge, the facility shall provide
     3  the patient and the insurer with a written discharge  plan  which  shall
     4  describe arrangements for additional services needed following discharge
     5  from  the  inpatient facility as determined using the evidence-based and
     6  peer-reviewed clinical review tool utilized  by  the  insurer  which  is
     7  designated  by  the  office of [alcoholism and substance abuse services]
     8  addiction services and supports. Prior to discharge, the facility  shall
     9  indicate  to the insurer whether services included in the discharge plan
    10  are secured or determined to be  reasonably  available.  [Any]  Insurers
    11  shall  actively participate in facility-initiated periodic consultations
    12  prior to the patient's discharge and except where the insurer  fails  to
    13  do  so, any utilization review of treatment provided under this subpara-
    14  graph may include a review of all services provided  during  such  inpa-
    15  tient  treatment, including all services provided during the first twen-
    16  ty-eight days  of  such  inpatient  treatment.  Provided,  however,  the
    17  insurer  shall  be  required to process claims for the provision of such
    18  services within the timeframes established in subsection (a) of  section
    19  three  thousand two hundred twenty-four-a of this article and shall only
    20  deny coverage for any portion of the initial twenty-eight day  inpatient
    21  treatment  on  the basis that such treatment was not medically necessary
    22  if such inpatient treatment was contrary to the evidence-based and  peer
    23  reviewed  clinical  review  tool utilized by the insurer which is desig-
    24  nated by  the  office  of  [alcoholism  and  substance  abuse  services]
    25  addiction services and supports. An insured shall not have any financial
    26  obligation  to  the  facility  for any treatment under this subparagraph
    27  other than any copayment, coinsurance, or deductible otherwise  required
    28  under the policy.
    29    § 6. Subparagraph (E) of paragraph 7 of subsection (l) of section 3221
    30  of  the  insurance law, as amended by section 17 of subpart A of part BB
    31  of chapter 57 of the laws of 2019, is amended to read as follows:
    32    (E) This subparagraph shall apply to facilities in this state that are
    33  licensed, certified or otherwise authorized by the office of [alcoholism
    34  and substance abuse services] addiction services and  supports  for  the
    35  provision of outpatient, intensive outpatient, outpatient rehabilitation
    36  and  opioid  treatment  that are participating in the insurer's provider
    37  network. Coverage provided under this paragraph shall not be subject  to
    38  preauthorization.  Coverage  provided  under this paragraph shall not be
    39  subject to concurrent review for the  first  four  weeks  of  continuous
    40  treatment,  not  to  exceed  twenty-eight  visits, provided the facility
    41  notifies the insurer of both the start  of  treatment  and  the  initial
    42  treatment plan within two business days on a standardized form developed
    43  by  the department in consultation with the department of health and the
    44  office of addiction services and supports. The  facility  shall  perform
    45  clinical  assessment  of the patient at each visit[, including periodic]
    46  and consult  periodically  with  the  insurer  regarding  the  patient's
    47  progress, course of treatment, and discharge plan. Periodic consultation
    48  with  the  insurer  [at  or just prior to] shall occur no later than the
    49  fourteenth day of treatment [to ensure that the facility  is  using  the
    50  evidence-based  and  peer  reviewed clinical review tool utilized by the
    51  insurer which is designated by the office of  alcoholism  and  substance
    52  abuse services and appropriate to the age of the patient, to ensure that
    53  the  outpatient treatment is medically necessary for the patient]. [Any]
    54  Insurers  shall  actively  participate  in  facility-initiated  periodic
    55  consultations  prior  to  the  patient's  discharge and except where the
    56  insurer fails to do so, any utilization review of the treatment provided
        S. 5300                             6

     1  under this subparagraph may include a review of  all  services  provided
     2  during such outpatient treatment, including all services provided during
     3  the first four weeks of continuous treatment, not to exceed twenty-eight
     4  visits,  of  such  outpatient  treatment. Provided, however, the insurer
     5  shall only deny coverage for any portion of the initial  four  weeks  of
     6  continuous  treatment, not to exceed twenty-eight visits, for outpatient
     7  treatment on the basis that such treatment was not  medically  necessary
     8  if such outpatient treatment was contrary to the evidence-based and peer
     9  reviewed  clinical  review  tool utilized by the insurer which is desig-
    10  nated by  the  office  of  [alcoholism  and  substance  abuse  services]
    11  addiction  services  and supports.  An insured shall not have any finan-
    12  cial obligation to the facility for any treatment  under  this  subpara-
    13  graph  other  than  any  copayment, coinsurance, or deductible otherwise
    14  required under the policy.
    15    § 7. Subsection (a) of section 3224-a of the insurance law, as amended
    16  by chapter 237 of the laws of 2009, is amended to read as follows:
    17    (a) Except in a case where the obligation of an insurer or  an  organ-
    18  ization  or corporation licensed or certified pursuant to article forty-
    19  three or forty-seven of this chapter or article forty-four of the public
    20  health law to pay a claim submitted by a policyholder or person  covered
    21  under  such policy ("covered person") or make a payment to a health care
    22  provider is not reasonably clear, or when there is  a  reasonable  basis
    23  supported  by  specific  information  available for review by the super-
    24  intendent that such claim or bill for health care services rendered  was
    25  submitted  fraudulently,  such  insurer  or  organization or corporation
    26  shall pay the claim to a  policyholder  or  covered  person  or  make  a
    27  payment  to  a  health  care provider within thirty days of receipt of a
    28  claim or bill for services rendered that is transmitted via the internet
    29  or electronic mail, or forty-five days of receipt of a claim or bill for
    30  services rendered that is submitted by other means,  such  as  paper  or
    31  facsimile.  The obligation of an insurer or organization to make payment
    32  to a health care provider for mental health or  substance  use  disorder
    33  services  that  are not subject to preauthorization or concurrent review
    34  pursuant to sections three thousand two hundred sixteen, three  thousand
    35  two  hundred  twenty-one,  or  four thousand three hundred three of this
    36  chapter shall not be considered not reasonably clear solely because  the
    37  insurer  or  organization  intends to perform concurrent review for such
    38  services before or after the expiration of the timeframes established by
    39  this subsection.
    40    § 8. Paragraph 8 of subsection (g) of section 4303  of  the  insurance
    41  law, as added by section 23 of subpart A of part BB of chapter 57 of the
    42  laws of 2019, is amended to read as follows:
    43    (8)  This  paragraph  shall  apply to hospitals in this state that are
    44  licensed, certified or otherwise authorized  by  the  office  of  mental
    45  health  that are participating in the [corporation's] insurer's provider
    46  network. Where the contract provides  coverage  for  inpatient  hospital
    47  care,  benefits  for inpatient hospital care in a hospital as defined by
    48  subdivision ten of section 1.03 of the mental hygiene law  [provided  to
    49  individuals  who  have  not  attained  the age of eighteen] shall not be
    50  subject to preauthorization.  Coverage  provided  under  this  paragraph
    51  shall  also  not  be subject to concurrent utilization review during the
    52  first fourteen days of the inpatient admission,  provided  the  facility
    53  notifies the [corporation] insurer of both the admission and the initial
    54  treatment  plan within two business days of the admission on a standard-
    55  ized form developed by the department in consultation with  the  depart-
    56  ment  of health and the office of mental health, performs daily clinical
        S. 5300                             7

     1  review of the patient, and [participates in periodic  consultation  with
     2  the  corporation to ensure that the facility is using the evidence-based
     3  and peer reviewed clinical review criteria utilized by  the  corporation
     4  which  is approved by the office of mental health and appropriate to the
     5  age of the patient, to ensure  that  the  inpatient  care  is  medically
     6  necessary  for  the  patient]  consults  periodically  with  the insurer
     7  regarding the patient's progress, course  of  treatment,  and  discharge
     8  plan.    [All] Insurers shall actively participate in facility-initiated
     9  periodic consultations prior to the patient's discharge and except where
    10  the insurer fails to do so, all treatment provided under this  paragraph
    11  may  be  reviewed retrospectively. Where care is denied retrospectively,
    12  an insured shall not have any financial obligation to the  facility  for
    13  any  treatment  under  this  paragraph other than any copayment, coinsu-
    14  rance, or deductible otherwise required under the contract.
    15    § 9. Paragraph 4 of subsection (k) of section 4303  of  the  insurance
    16  law,  as  amended by section 26 of subpart A of part BB of chapter 57 of
    17  the laws of 2019, is amended to read as follows:
    18    (4) This paragraph shall apply to facilities in this  state  that  are
    19  licensed, certified or otherwise authorized by the office of [alcoholism
    20  and  substance  abuse services] addiction services and supports that are
    21  participating in the [corporation's] insurer's provider network.  Cover-
    22  age  provided  under this subsection shall not be subject to preauthori-
    23  zation. Coverage provided  under  this  subsection  shall  also  not  be
    24  subject  to  concurrent utilization review during the first twenty-eight
    25  days of the inpatient admission provided that the facility notifies  the
    26  [corporation]  insurer  of  both the admission and the initial treatment
    27  plan within two business days of the admission on  a  standardized  form
    28  developed  by  the  department  in  consultation  with the department of
    29  health and the office of addiction services and supports.  The  facility
    30  shall  perform daily clinical review of the patient[, including periodic
    31  consultation] and consult periodically with the  insurer  regarding  the
    32  patient's  progress,  course of treatment, and discharge plan.  Periodic
    33  consultation with the [corporation at or just prior  to]  insurer  shall
    34  occur not later than the fourteenth day of treatment [to ensure that the
    35  facility  is  using the evidence-based and peer reviewed clinical review
    36  tool utilized by the corporation which is designated by  the  office  of
    37  alcoholism  and  substance  abuse services and appropriate to the age of
    38  the patient, to ensure that the inpatient treatment is medically  neces-
    39  sary  for  the  patient]. Prior to discharge, the facility shall provide
    40  the patient and the [corporation] insurer with a written discharge  plan
    41  which shall describe arrangements for additional services needed follow-
    42  ing  discharge  from  the  inpatient  facility  as  determined using the
    43  evidence-based and peer-reviewed clinical review tool  utilized  by  the
    44  [corporation]  insurer  which is designated by the office of [alcoholism
    45  and substance abuse services] addiction services and supports. Prior  to
    46  discharge,  the  facility  shall  indicate  to the [corporation] insurer
    47  whether services included in the discharge plan are  secured  or  deter-
    48  mined to be reasonably available.  [Any] Insurers shall actively partic-
    49  ipate   in   facility-initiated  periodic  consultations  prior  to  the
    50  patient's discharge and except where the insurer fails  to  do  so,  any
    51  utilization  review  of  treatment  provided  under  this  paragraph may
    52  include a review of all services provided during such  inpatient  treat-
    53  ment, including all services provided during the first twenty-eight days
    54  of such inpatient treatment. Provided, however, the [corporation] insur-
    55  er  shall  be  required  to  process  claims  for  the provision of such
    56  services within the timeframes established in subsection (a) of  section
        S. 5300                             8

     1  three  thousand two hundred twenty-four-a of this chapter and shall only
     2  deny coverage for any portion of the initial twenty-eight day  inpatient
     3  treatment  on  the basis that such treatment was not medically necessary
     4  if  such inpatient treatment was contrary to the evidence-based and peer
     5  reviewed clinical review tool  utilized  by  the  [corporation]  insurer
     6  which  is  designated  by  the office of [alcoholism and substance abuse
     7  services] addiction services and supports.   An insured shall  not  have
     8  any  financial  obligation  to the facility for any treatment under this
     9  paragraph other than any copayment, coinsurance, or deductible otherwise
    10  required under the contract.
    11    § 10. Paragraph 5 of subsection (l) of section 4303 of  the  insurance
    12  law,  as  amended by section 28 of subpart A of part BB of chapter 57 of
    13  the laws of 2019, is amended to read as follows:
    14    (5) This paragraph shall apply to facilities in this  state  that  are
    15  licensed, certified or otherwise authorized by the office of [alcoholism
    16  and  substance  abuse  services] addiction services and supports for the
    17  provision of outpatient, intensive outpatient, outpatient rehabilitation
    18  and opioid treatment that are participating in the corporation's provid-
    19  er network. Coverage provided under this subsection shall not be subject
    20  to preauthorization. Coverage provided under this subsection  shall  not
    21  be  subject  to concurrent review for the first four weeks of continuous
    22  treatment, not to exceed  twenty-eight  visits,  provided  the  facility
    23  notifies  the corporation of both the start of treatment and the initial
    24  treatment plan within two business days on a standardized form developed
    25  by the department in consultation with the department of health and  the
    26  office  of  addiction  services and supports. The facility shall perform
    27  clinical assessment of the patient at each visit[,  including  periodic]
    28  and  consult  periodically  with  the  insurer  regarding  the patient's
    29  progress, course of treatment, and discharge plan. Periodic consultation
    30  with the corporation [at or just prior to] shall occur no later than the
    31  fourteenth day of treatment [to ensure that the facility  is  using  the
    32  evidence-based  and  peer  reviewed clinical review tool utilized by the
    33  corporation  which  is  designated  by  the  office  of  alcoholism  and
    34  substance  abuse  services and appropriate to the age of the patient, to
    35  ensure that the outpatient treatment  is  medically  necessary  for  the
    36  patient]. [Any] Insurers shall actively participate in facility-initiat-
    37  ed  periodic  consultations  prior to the patient's discharge and except
    38  where the insurer fails to do so, any utilization review of  the  treat-
    39  ment  provided under this paragraph may include a review of all services
    40  provided  during  such  outpatient  treatment,  including  all  services
    41  provided  during  the  first  four weeks of continuous treatment, not to
    42  exceed twenty-eight visits, of such  outpatient  treatment.    Provided,
    43  however, the corporation shall only deny coverage for any portion of the
    44  initial  four  weeks of continuous treatment, not to exceed twenty-eight
    45  visits, for outpatient treatment on the basis that  such  treatment  was
    46  not medically necessary if such outpatient treatment was contrary to the
    47  evidence-based  and  peer  reviewed clinical review tool utilized by the
    48  corporation which  is  designated  by  the  office  of  [alcoholism  and
    49  substance  abuse services] addiction services and supports. [A subscrib-
    50  er] An insured shall not have any financial obligation to  the  facility
    51  for any treatment under this paragraph other than any copayment, coinsu-
    52  rance, or deductible otherwise required under the contract.
    53    §  11.  Section  109  of  the insurance law is amended by adding a new
    54  subsection (e) to read as follows:
    55    (e) In addition to any right of action granted to  the  superintendent
    56  pursuant to this section, any person who has been injured by reason of a
        S. 5300                             9

     1  violation of paragraphs thirty, thirty-one, thirty-one-a and thirty-five
     2  of  subsection  (i) of section three thousand two hundred sixteen, para-
     3  graphs five, six, seven and seven-a of subsection (l) of  section  three
     4  thousand  two hundred twenty-one, and subsections (g), (k), (l) or (l-1)
     5  of section four thousand three hundred  three  of  this  chapter  by  an
     6  insurer subject to article thirty-two or forty-three of this chapter may
     7  bring  an  action  in his or her own name to enjoin such unlawful act or
     8  practice, an action to recover his or her actual damages or one thousand
     9  dollars, whichever is greater, or both such actions. The court  may,  in
    10  its  discretion,  award the prevailing plaintiff in such action an addi-
    11  tional award not to exceed five thousand dollars, if the court finds the
    12  defendant willfully violated the provisions of this section.  The  court
    13  may award reasonable attorneys' fees to a prevailing plaintiff.
    14    § 12. This act shall take effect January 1, 2025.

    15                                   PART B

    16    Section  1.  Subparagraph  (A)  of paragraph 31-a of subsection (i) of
    17  section 3216 of the insurance law, as added by chapter 748 of  the  laws
    18  of 2019, is amended to read as follows:
    19    (A)  No policy that provides medical, major medical or similar compre-
    20  hensive-type coverage and provides coverage for prescription  drugs  for
    21  medication  for  the treatment of a substance use disorder shall require
    22  prior authorization for an initial  or  renewal  prescription  for  such
    23  drugs for the detoxification or maintenance of a substance use disorder,
    24  including  all  buprenorphine  products,  methadone  [or],  long  acting
    25  injectable naltrexone [for detoxification or maintenance treatment of  a
    26  substance  use  disorder]  and  medication  for opioid overdose reversal
    27  prescribed or dispensed to  an  individual  covered  under  the  policy,
    28  except where otherwise prohibited by law.
    29    §  2.  Subparagraph  (A) of paragraph 7-a of subsection (l) of section
    30  3221 of the insurance law, as added by chapter 748 of the laws of  2019,
    31  is amended to read as follows:
    32    (A)  No policy that provides medical, major medical or similar compre-
    33  hensive-type small group coverage and provides coverage for prescription
    34  drugs for medication for the treatment of a substance use disorder shall
    35  require prior authorization for an initial or renewal  prescription  for
    36  such  drugs  for  the  detoxification  or maintenance of a substance use
    37  disorder, including all buprenorphine products, methadone,  long  acting
    38  injectable  naltrexone,  and  medication  for  opioid  overdose reversal
    39  prescribed or dispensed to  an  individual  covered  under  the  policy,
    40  except  where  otherwise  prohibited  by law. Every policy that provides
    41  medical, major medical or similar comprehensive-type large group  cover-
    42  age shall provide coverage for prescription drugs for medication for the
    43  treatment of a substance use disorder and shall provide immediate cover-
    44  age for all buprenorphine products, methadone [or], long acting injecta-
    45  ble  naltrexone,  and medication for opioid overdose reversal prescribed
    46  or dispensed to an individual covered under  the  policy  without  prior
    47  authorization  for  the  detoxification  or  maintenance  treatment of a
    48  substance use disorder, except where otherwise prohibited by law.
    49    § 3. Paragraph (A) of subsection (l-1) of section 4303 of  the  insur-
    50  ance  law,  as  added  by chapter 748 of the laws of 2019, is amended to
    51  read as follows:
    52    (A) No contract  that  provides  medical,  major  medical  or  similar
    53  comprehensive-type  individual  or  small  group  coverage  and provides
    54  coverage for prescription drugs for medication for the  treatment  of  a
        S. 5300                            10

     1  substance  use disorder shall require prior authorization for an initial
     2  or renewal prescription for such drugs for the detoxification or mainte-
     3  nance of a substance use disorder, including all buprenorphine products,
     4  methadone,  long acting injectable naltrexone, and medication for opioid
     5  overdose reversal prescribed or dispensed to an individual covered under
     6  the contract, except where otherwise prohibited by law.  Every  contract
     7  that  provides  medical,  major  medical,  or similar comprehensive-type
     8  large group coverage shall provide coverage for prescription  drugs  for
     9  medication  for  the  treatment  of  a  substance use disorder and shall
    10  provide immediate coverage for  all  buprenorphine  products,  methadone
    11  [or], long acting injectable naltrexone, and medication for opioid over-
    12  dose reversal prescribed or dispensed to an individual covered under the
    13  contract  without  prior authorization for the detoxification or mainte-
    14  nance treatment of a substance  use  disorder,  except  where  otherwise
    15  prohibited by law.
    16    § 4. This act shall take effect immediately.
    17    § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
    18  sion,  section  or  part  of  this act shall be adjudged by any court of
    19  competent  jurisdiction to be invalid, such judgment  shall  not affect,
    20  impair,  or  invalidate  the remainder thereof, but shall be confined in
    21  its operation to the clause, sentence, paragraph, subdivision,   section
    22  or part thereof directly involved in the controversy in which such judg-
    23  ment shall have been rendered. It is hereby declared to be the intent of
    24  the  legislature  that  this  act  would  have been enacted even if such
    25  invalid provisions had not been included herein.
    26    § 3. This act shall take effect immediately  provided,  however,  that
    27  the  applicable effective date of Parts A through B of this act shall be
    28  as specifically set forth in the last section of such Parts.