senate Bill S7882

Relates to insurance coverage for diagnosis and treatment of substance use disorder benefits

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Bill Status


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor
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actions

  • 16 / Jun / 2014
    • REFERRED TO RULES

Summary

Relates to insurance coverage for diagnosis and treatment of substance use disorder benefits; creates a workgroup to study and make recommendations on improving access to and the availability of chemical dependency or substance use disorder treatment services.

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Bill Details

See Assembly Version of this Bill:
A9943B
Versions:
S7882
Legislative Cycle:
2013-2014
Current Committee:
Senate Rules
Law Section:
Insurance Law
Laws Affected:
Amd §§3216, 3221, 4303, 4902, 4903 & 4904, Ins L; amd §§4902, 4903 & 4904, Pub Health L

Sponsor Memo

BILL NUMBER:S7882

TITLE OF BILL: An act to amend the insurance law and the public
health law, in relation to requiring health insurance coverage for
diagnosis and treatment of substance use disorder treatment services
and creating a workgroup to study and make recommendations

PURPOSE: This legislation clarifies that health insurance coverage
must provide for substance abuse disorder treatment services improves
the utilization review process for determining such insurance coverage
and requires insurers to continue to provide coverage throughout the
entire appeals process.

SUMMARY OF PROVISIONS: Sections one, two and three amend sections
3216, 3221 and 4303 of the insurance law to clarify that health plans
shall include specific coverage for drug and alcohol abuse and
dependency treatment services pursuant to the federal Mental Health
and Parity Act of 2008 and applicable state statutes. It also requires
a health plan to use a health care provider who specializes in
substance abuse disorder treatment when conducting medical management
or utilization review and requires the use of evidence-based and
peer-reviewed clinical review criteria as deemed appropriate and
approved by OASAS in consultation with DFS and DOH. This section also
requires all internal and external appeals to be conducted on an
expedited basis and health plans to provide coverage for substance
abuse services until all appeals, both internal and external, have
been exhausted.

Sections four through nine make similar corresponding changes in
sections 4902, 4903, and 4904 of the insurance law, and sections 4902,
4903 and 4904 of the public health law.

Section ten requires DFS to select a random sampling of substance
abuse coverage determinations and provide an analysis of whether or
not such determinations are in compliance with the criteria
established in this act and to submit a report by December 31, 2015.

Section eleven creates a workgroup to study and make recommendations
on improving access to and availability of substance abuse and
dependency treatment services. The workgroup shall submit a report by
December 31, 2015.

Section twelve provides for a January 1, 2015.

JUSTIFICATION: The New York State Senate Heroin and Opioid Task Force
has held hearings throughout the state to discuss the rise in the use
of heroin and other opioids in New York State and to develop
recommendations for treating and preventing addiction. At each of
these hearings, the issue of health insurance coverage has been at the
forefront. This legislation will improve access to care by ensuring
that decisions regarding treatment are standardized and that they are
made by medical doctors who specialize in behavioral health and
substance abuse. Further, the legislation also ensures that
individuals requiring treatment have access to an expedited appeals
process and that they are not denied care while the appeals process is
underway. The legislation also establishes a workgroup to be convened
jointly with OASAS, DFS and DOH in order to study and develop


recommendations on improving access to and availability of substance
abuse and dependency treatment services.

LEGISLATIVE HISTORY: New bill.

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: Jan 1, 2015

view bill text
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  7882

                            I N  S E N A T E

                              June 16, 2014
                               ___________

Introduced  by  Sens.  SEWARD, HANNON -- read twice and ordered printed,
  and when printed to be committed to the Committee on Rules

AN ACT to amend the insurance law and the public health law, in relation
  to requiring health insurance coverage for diagnosis and treatment  of
  substance  use disorder treatment services and creating a workgroup to
  study and make recommendations

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.    Subsection  (i) of section 3216 of the insurance law is
amended by adding a new paragraph 30 to read as follows:
  (30) (A) EVERY POLICY THAT PROVIDES MEDICAL, MAJOR-MEDICAL OR  SIMILAR
COMPREHENSIVE-TYPE  COVERAGE  SHALL  INCLUDE  COVERAGE FOR DIAGNOSIS AND
TREATMENT OF SUBSTANCE USE DISORDER BENEFITS  PURSUANT  TO  THE  FEDERAL
PAUL  WELLSTONE  AND  PETE  DOMENICI  MENTAL HEALTH PARITY AND ADDICTION
EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE  FEDERAL  AND  STATE
STATUTES  AND  RULES  AND  REGULATIONS PROMULGATED THERETO WHICH REQUIRE
PARITY BETWEEN MENTAL HEALTH OR  SUBSTANCE  USE  DISORDER  BENEFITS  AND
MEDICAL/SURGICAL  BENEFITS  WITH  RESPECT  TO FINANCIAL REQUIREMENTS AND
TREATMENT  OR  WHICH  REQUIRE  COVERAGE  OF  SUCH  TREATMENT,  WHICHEVER
PROVIDES  A  BENEFIT  THAT  IS  MORE ADVANTAGEOUS TO THE POLICYHOLDER AS
DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION  AND  REHABILI-
TATION SERVICES.
  (B)  IN THE EVENT OF AN ADVERSE DETERMINATION FOR SUBSTANCE USE DISOR-
DER TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE COVER-
AGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL THE INSURED HAS  EXHAUSTED
ALL  APPEALS,  BOTH  INTERNAL  AND  EXTERNAL,  OR OTHERWISE NOTIFIES THE
HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED TO  NOT  MOVE  FORWARD
WITH  THE APPEALS PROCESS.  THE HEALTH PLAN SHALL ENSURE THAT AN INSURED
SHALL NOT INCUR ANY GREATER OUT-OF-POCKET COSTS FOR SUBSTANCE USE DISOR-
DER TREATMENT SERVICES RENDERED  WHILE  THE  PROVIDER  IS  APPEALING  AN
ADVERSE  DETERMINATION  FOR  SUCH  SERVICES  THAN THE INSURED WOULD HAVE
INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILIZATION REVIEW AGENT.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD15361-11-4

S. 7882                             2

  S 2. Subsection (l) of section 3221 of the insurance law is amended by
adding a new paragraph 19 to read as follows:
  (19)  (A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR DELIV-
ERY IN THIS STATE WHICH PROVIDES MAJOR  MEDICAL  OR  SIMILAR  COMPREHEN-
SIVE-TYPE  COVERAGE  SHALL  INCLUDE  SPECIFIC COVERAGE FOR DIAGNOSIS AND
TREATMENT OF SUBSTANCE USE DISORDER BENEFITS  PURSUANT  TO  THE  FEDERAL
PAUL  WELLSTONE  AND  PETE  DOMENICI  MENTAL HEALTH PARITY AND ADDICTION
EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE  FEDERAL  AND  STATE
STATUTES  AND  RULES  AND  REGULATIONS PROMULGATED THERETO WHICH REQUIRE
PARITY BETWEEN MENTAL HEALTH OR  SUBSTANCE  USE  DISORDER  BENEFITS  AND
MEDICAL/SURGICAL  BENEFITS  WITH  RESPECT  TO FINANCIAL REQUIREMENTS AND
TREATMENT  OR  WHICH  REQUIRE  COVERAGE  OF  SUCH  TREATMENT,  WHICHEVER
PROVIDES  A  BENEFIT  THAT  IS  MORE ADVANTAGEOUS TO THE POLICYHOLDER AS
DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION  AND  REHABILI-
TATION SERVICES.
  (B)  IN  THE EVENT OF AN ADVERSE DETERMINATION FOR CHEMICAL DEPENDENCE
OR SUBSTANCE USE DISORDER TREATMENT  SERVICES,  THE  HEALTH  PLAN  SHALL
CONTINUE  TO  PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL
THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL  AND  EXTERNAL,  OR
OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED
TO  NOT  MOVE  FORWARD  WITH THE APPEALS PROCESS.  THE HEALTH PLAN SHALL
ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER  OUT-OF-POCKET  COSTS
FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID-
ER  IS  APPEALING  AN  ADVERSE  DETERMINATION FOR SUCH SERVICES THAN THE
INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI-
ZATION REVIEW AGENT.
  S 3. Section 4303 of the insurance law is  amended  by  adding  a  new
subsection (oo) to read as follows:
  (OO)  (1)  A MEDICAL EXPENSE INDEMNITY CORPORATION, A HOSPITAL SERVICE
CORPORATION OR A HEALTH SERVICE CORPORATION WHICH PROVIDES MAJOR MEDICAL
OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE  SPECIFIC  COVERAGE
FOR  DIAGNOSIS AND TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT
TO THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND
ADDICTION EQUITY ACT OF 2008, AS AMENDED, OR  OTHER  APPLICABLE  FEDERAL
AND  STATE  STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH
REQUIRE PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER  BENEFITS
AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND
TREATMENT  OR  WHICH  REQUIRE  COVERAGE  OF  SUCH  TREATMENT,  WHICHEVER
PROVIDES A BENEFIT THAT IS MORE  ADVANTAGEOUS  TO  THE  POLICYHOLDER  AS
DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA-
TIENT  AND  OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI-
TATION SERVICES.
  (2) IN THE EVENT OF AN ADVERSE DETERMINATION FOR  CHEMICAL  DEPENDENCE
OR  SUBSTANCE  USE  DISORDER  TREATMENT  SERVICES, THE HEALTH PLAN SHALL
CONTINUE TO PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH  SERVICES  UNTIL
THE  INSURED  HAS  EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR
OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED
TO NOT MOVE FORWARD WITH THE APPEALS PROCESS.   THE  HEALTH  PLAN  SHALL
ENSURE  THAT  AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF POCKET COSTS
FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID-
ER IS APPEALING AN ADVERSE DETERMINATION  FOR  SUCH  SERVICES  THAN  THE
INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI-
ZATION REVIEW AGENT.
  S  4.  Section  4902 of the insurance law is amended by adding two new
subsections (c) and (d) to read as follows:

S. 7882                             3

  (C) I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF  DETERMIN-
ING HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISOR-
DERS,  A  UTILIZATION  REVIEW  AGENT SHALL BE A HEALTH CARE PROVIDER WHO
SPECIALIZES IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE  DELIVERY
OF CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER COURSES OF TREATMENT TO
SUPERVISE  AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO SUCH
TREATMENT.
  II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED
AND PEER REVIEWED CLINICAL REVIEW CRITERIA THAT IS  APPROPRIATE  TO  THE
AGE  OF  THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR SUCH USE
BY THE COMMISSIONER OF THE OFFICE  OF  ALCOHOLISM  AND  SUBSTANCE  ABUSE
SERVICES  IN CONSULTATION WITH THE COMMISSIONER OF HEALTH AND THE SUPER-
INTENDENT.
  III. THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN  CONSUL-
TATION  WITH  THE  COMMISSIONER  OF  HEALTH AND THE SUPERINTENDENT SHALL
APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER  REVIEWED  CLINICAL  REVIEW
CRITERIA,  IN  ADDITION  TO  ANY  OTHER APPROVED EVIDENCE-BASED AND PEER
REVIEWED CLINICAL REVIEW CRITERIA.
  (D) WHERE AN  INSURED'S  HEALTHCARE  PROVIDER  BELIEVES  AN  IMMEDIATE
APPEAL  OF  AN  ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL
DEPENDENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL  APPEALS
SHALL  BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B)
OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE.    WHERE  AN
INSURED'S  HEALTH  CARE  PROVIDER  DETERMINES  THAT A DELAY IN PROVIDING
CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER  TREATMENT  WOULD  POSE  A
SERIOUS  THREAT TO THE HEALTH OR SAFETY OF THE INSURED, EXTERNAL APPEALS
OF UTILIZATION REVIEW DETERMINATION WILL BE CONDUCTED  ON  AN  EXPEDITED
BASIS  AS SET FORTH IN PARAGRAPH THREE OF SUBSECTION (B) OF SECTION FOUR
THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
  S 5. Subsection (c) of section 4903 of the insurance law,  as  amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (c)  A  utilization  review agent shall make a determination involving
continued or extended health care services, additional services  for  an
insured  undergoing  a  course  of  continued  treatment prescribed by a
health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE  OR
SUBSTANCE  USE DISORDER, or home health care services following an inpa-
tient hospital admission, and shall provide notice of such determination
to the insured or the insured's designee,  which  may  be  satisfied  by
notice  to the insured's health care provider, by telephone and in writ-
ing within one business day of  receipt  of  the  necessary  information
except, with respect to home health care services following an inpatient
hospital  admission OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER, within  seventy-two  hours  of  receipt  of  the
necessary  information when the day subsequent to the request falls on a
weekend or holiday. Notification of continued or extended services shall
include the number of extended  services  approved,  the  new  total  of
approved  services,  the  date  of onset of services and the next review
date. Provided that a request for home  health  care  services  and  all
necessary information is submitted to the utilization review agent prior
to  discharge  from  an  inpatient  hospital  admission pursuant to this
subsection, a utilization review agent shall not deny, on the  basis  of
medical  necessity  or  lack  of  prior authorization, coverage for home
health care services while a determination  by  the  utilization  review
agent  is  pending.  PROVIDED  THAT A REQUEST FOR TREATMENT FOR CHEMICAL
DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL  NECESSARY  INFORMATION  IS
SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBSECTION, A

S. 7882                             4

UTILIZATION  REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECES-
SITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER TREATMENT WHILE A DETERMINATION BY  THE  UTILIZA-
TION REVIEW AGENT IS PENDING.  PROVIDED THAT UPON ADMISSION TO INPATIENT
AND  RESIDENTIAL  TREATMENT  FOR  CHEMICAL  DEPENDENCY  OR SUBSTANCE USE
DISORDER, THE UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE  BASIS  OF
MEDICAL  NECESSITY OR LACK OF PRIOR AUTHORIZATION, WHEN NOTICE OF ADMIS-
SION FOR PURPOSES OF CARE COORDINATION WAS PROVIDED TO  THE  UTILIZATION
REVIEW AGENT WITHIN TWENTY-FOUR HOURS OF AN ADMISSION; AND A REQUEST FOR
TREATMENT  FOR  CHEMICAL  DEPENDENCE  OR  SUBSTANCE USE DISORDER AND ALL
NECESSARY INFORMATION IS  SUBMITTED  TO  THE  UTILIZATION  REVIEW  AGENT
PURSUANT TO THIS SUBSECTION.
  S  6.  Subsection (b) of section 4904 of the insurance law, as amended
by chapter 237 of the laws of 2009, is amended to read as follows:
  (b) A utilization review agent shall  establish  an  expedited  appeal
process  for  appeal of an adverse determination involving (1) continued
or extended health care services, procedures or treatments or additional
services for an insured  undergoing  a  course  of  continued  treatment
prescribed  by  a  health  care  provider  or  home health care services
following discharge from an inpatient  hospital  admission  pursuant  to
subsection (c) of section four thousand nine hundred three of this arti-
cle  or  (2)  an adverse determination in which the health care provider
believes an immediate  appeal  is  warranted  except  any  retrospective
determination.  Such  process  shall include mechanisms which facilitate
resolution of the appeal including but not limited  to  the  sharing  of
information  from the insured's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent shall provide reasonable access  to  its  clinical  peer  reviewer
within  one  business  day of receiving notice of the taking of an expe-
dited appeal. Expedited appeals shall be determined within two  business
days  of  receipt of necessary information to conduct such appeal. Expe-
dited appeals which do not result in a resolution  satisfactory  to  the
appealing  party  may  be  further  appealed through the standard appeal
process, or through the external appeal process pursuant to section four
thousand nine hundred fourteen of this article as  applicable.  PROVIDED
THAT  THE  INSURED  OR  THE  INSURED'S HEALTH CARE PROVIDER NOTIFIES THE
UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL  IMME-
DIATELY  UPON  RECEIPT  OF  AN APPEAL DETERMINATION AND A REQUEST FOR AN
EXPEDITED EXTERNAL  APPEAL  FOR  TREATMENT  OF  CHEMICAL  DEPENDENCE  OR
SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN
TWENTY-FOUR  HOURS  OF RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION
REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY  OR  LACK
OF  PRIOR  AUTHORIZATION,  COVERAGE  FOR SUCH TREATMENT WHILE A DETERMI-
NATION BY THE EXTERNAL REVIEW AGENT IS PENDING.
  S 7. Section 4902 of the public health law is amended  by  adding  two
new subdivisions 3 and 4 to read as follows:
  3. I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF DETERMINING
HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDERS,
A  UTILIZATION REVIEW AGENT SHALL BE A HEALTH CARE PROVIDER WHO SPECIAL-
IZES IN BEHAVIORAL HEALTH AND WHO HAS  EXPERIENCE  IN  THE  DELIVERY  OF
CHEMICAL  DEPENDENCE  OR  SUBSTANCE USE DISORDER COURSES OF TREATMENT TO
SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO  SUCH
TREATMENT.
  II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED
AND  PEER  REVIEWED  CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE
AGE OF THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR  SUCH  USE

S. 7882                             5

BY  THE  COMMISSIONER  OF  THE  OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE
SERVICES IN CONSULTATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF
FINANCIAL SERVICES.
  III.  THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSUL-
TATION  WITH  THE  COMMISSIONER  AND  THE  SUPERINTENDENT  OF  FINANCIAL
SERVICES  SHALL  APPROVE  A  RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED
CLINICAL  REVIEW  CRITERIA,  IN   ADDITION   TO   ANY   OTHER   APPROVED
EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA.
  4. WHERE AN INSURED'S HEALTHCARE PROVIDER BELIEVES AN IMMEDIATE APPEAL
OF  AN  ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL DEPEND-
ENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL APPEALS  SHALL
BE  CONDUCTED  ON  AN  EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B) OF
SECTION FOUR THOUSAND NINE  HUNDRED  FOUR  OF  THIS  TITLE.    WHERE  AN
ENROLLEE'S  HEALTH  CARE  PROVIDER  DETERMINES THAT A DELAY IN PROVIDING
CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER  TREATMENT  WOULD  POSE  A
SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE ENROLLEE, EXTERNAL APPEALS
OF  UTILIZATION  REVIEW DETERMINATIONS WILL BE CONDUCTED ON AN EXPEDITED
BASIS AS SET FORTH IN PARAGRAPH (C) OF SUBDIVISION TWO OF  SECTION  FOUR
THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE.
  S  8.  Subdivision  3  of  section  4903  of the public health law, as
amended by chapter 237 of the laws  of  2009,  is  amended  to  read  as
follows:
  3.  A  utilization  review  agent shall make a determination involving
continued or extended health care services, additional services  for  an
enrollee  undergoing  a  course  of  continued treatment prescribed by a
health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE  OR
SUBSTANCE  USE DISORDER, or home health care services following an inpa-
tient hospital admission, and shall provide notice of such determination
to the enrollee or the enrollee's designee, which may  be  satisfied  by
notice to the enrollee's health care provider, by telephone and in writ-
ing  within  one  business  day  of receipt of the necessary information
except, with respect to home health care services following an inpatient
hospital admission, OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR
SUBSTANCE USE DISORDER, within  seventy-two  hours  of  receipt  of  the
necessary  information when the day subsequent to the request falls on a
weekend or holiday. Notification of continued or extended services shall
include the number of extended  services  approved,  the  new  total  of
approved  services,  the  date  of onset of services and the next review
date. Provided that a request for home  health  care  services  and  all
necessary information is submitted to the utilization review agent prior
to  discharge  from  an  inpatient  hospital  admission pursuant to this
subdivision, a utilization review agent shall not deny, on the basis  of
medical  necessity  or  lack  of  prior authorization, coverage for home
health care services while a determination  by  the  utilization  review
agent  is  pending.   PROVIDED THAT A REQUEST FOR TREATMENT FOR CHEMICAL
DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL  NECESSARY  INFORMATION  IS
SUBMITTED  TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBDIVISION,
A UTILIZATION REVIEW AGENT SHALL NOT  DENY,  ON  THE  BASIS  OF  MEDICAL
NECESSITY  OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPEND-
ENCE OR SUBSTANCE USE DISORDER TREATMENT SERVICES WHILE A  DETERMINATION
BY  THE UTILIZATION REVIEW AGENT IS PENDING.  PROVIDED THAT, UPON ADMIS-
SION TO INPATIENT AND  RESIDENTIAL  TREATMENT,  THE  UTILIZATION  REVIEW
AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR
AUTHORIZATION,  WHEN  NOTICE  OF  ADMISSION FOR PURPOSES OF CARE COORDI-
NATION WAS PROVIDED TO THE UTILIZATION REVIEW AGENT  WITHIN  TWENTY-FOUR
HOURS  OF  AN  ADMISSION;  AND A REQUEST FOR TREATMENT FOR SUBSTANCE USE

S. 7882                             6

DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED TO  THE  UTILIZATION
REVIEW AGENT PURSUANT TO THIS SUBDIVISION.
  S  9.  Subdivision  2  of  section  4904  of the public health law, as
amended by chapter 237 of the laws  of  2009,  is  amended  to  read  as
follows:
  2.  A  utilization  review  agent  shall establish an expedited appeal
process for appeal of an adverse determination involving:
  (a) continued or extended health care services, procedures  or  treat-
ments  or  additional  services  for  an enrollee undergoing a course of
continued treatment prescribed by a health  care  provider  home  health
care  services  following discharge from an inpatient hospital admission
pursuant to subdivision three of section  forty-nine  hundred  three  of
this article; or
  (b)  an  adverse  determination  in  which  the  health  care provider
believes an immediate  appeal  is  warranted  except  any  retrospective
determination.    Such process shall include mechanisms which facilitate
resolution of the appeal including but not limited  to  the  sharing  of
information from the enrollee's health care provider and the utilization
review agent by telephonic means or by facsimile. The utilization review
agent  shall  provide  reasonable  access  to its clinical peer reviewer
within one business day of receiving notice of the taking  of  an  expe-
dited appeal.  Expedited appeals shall be determined within two business
days  of  receipt of necessary information to conduct such appeal. Expe-
dited appeals which do not result in a resolution  satisfactory  to  the
appealing  party  may  be  further  appealed through the standard appeal
process, or through the external  appeal  process  pursuant  to  section
forty-nine  hundred  fourteen  of  this article as applicable.  PROVIDED
THAT THE INSURED OR THE INSURED'S  HEALTH  CARE  PROVIDER  NOTIFIES  THE
UTILIZATION  REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME-
DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND  A  REQUEST  FOR  AN
EXPEDITED  EXTERNAL  APPEAL  FOR  TREATMENT  OF  CHEMICAL  DEPENDENCE OR
SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN
TWENTY-FOUR HOURS OF RECEIPT OF AN APPEAL DETERMINATION,  A  UTILIZATION
REVIEW  AGENT  SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK
OF PRIOR AUTHORIZATION, COVERAGE FOR SUCH  TREATMENT  WHILE  A  DETERMI-
NATION BY THE EXTERNAL REVIEW AGENT IS PENDING.
  S 10. The superintendent of the department of financial services shall
select  a random sampling of chemical dependence or substance use disor-
der treatment coverage determinations and provide an analysis of whether
or not such determinations are in compliance with  the  criteria  estab-
lished in this act and report its finding to the governor, the temporary
president  of the senate, and speaker of the assembly, the chairs of the
senate and assembly insurance committees, and the chairs of  the  senate
and assembly health committees no later than December 31, 2015.
  S  11.  1.  Within  thirty days of the effective date of this act, the
commissioner of the office of alcoholism and substance  abuse  services,
superintendent  of the department of financial services, and the commis-
sioner of health, shall jointly convene a workgroup to  study  and  make
recommendations  on  improving  access  to  and availability of chemical
dependence or substance use disorder treatment services  in  the  state.
The  workgroup shall be co-chaired by such commissioners and superinten-
dent, and shall also include, but not be limited to, representatives  of
health  care  providers, insurers, additional professionals, individuals
and families who have been affected by addiction.  The  workgroup  shall
include, but not be limited to, a review of the following:

S. 7882                             7

  a.  Identifying barriers to obtaining necessary chemical dependence or
substance use disorder treatment services for across the state;
  b. Recommendations for increasing access to and availability of chemi-
cal  dependence  or  substance  use  disorder  treatment services in the
state, including underserved areas of the state;
  c. Identifying best clinical  practices  for  chemical  dependence  or
substance use disorder treatment services;
  d. A review of current insurance coverage requirements and recommenda-
tions  for  improving  insurance  coverage  for  chemical  dependence or
substance use disorder and dependency treatment;
  e.  Recommendations  for  improving  state  agency  communication  and
collaboration  relating to chemical dependence or substance use disorder
treatment services in the state;
  f. Resources for affected individuals  and  families  who  are  having
difficulties  obtaining  necessary  chemical dependence or substance use
disorder treatment services; and
  g. Methods for developing quality standards to measure the performance
of chemical dependence or substance use disorder treatment facilities in
the state.
  2. The workgroup shall submit a report of its findings and recommenda-
tions to the governor, the temporary president of the senate, the speak-
er of the assembly, the chairs of  the  senate  and  assembly  insurance
committees,  and the chairs of the senate and assembly health committees
no later than December 31, 2015.
  S 12. This act shall take effect January 1, 2015;  provided,  however,
that  sections  one through nine of this act shall apply to all policies
and contracts issued, delivered, renewed, modified, altered, or  amended
after such date.

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