Senate Bill S4867A

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4867
 
                        2025-2026 Regular Sessions
 
                             I N  S E N A T E
 
                             February 13, 2025
                                ___________
 
 Introduced  by  Sen.  FAHY  --  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 prohibiting the appli-
   cation of fail-first or step therapy protocols  to  coverage  for  the
   diagnosis and treatment of serious mental health conditions

   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Item (ii) of subparagraph (A) and subparagraphs (C) and (E)
 of paragraph 35 of subsection (i) of section 3216 of the insurance  law,
 item  (ii)  of  subparagraph (A) as amended by chapter 62 of the laws of
 2023 and subparagraphs (C) and (E) as added by section 8 of subpart A of
 part BB of chapter 57 of the laws  of  2019,  are  amended  to  read  as
 follows:
   (ii)  where  the policy provides coverage for physician services, such
 policy shall include benefits for outpatient care provided by a psychia-
 trist or psychologist licensed to practice in  this  state,  a  licensed
 clinical  social  worker  within  the lawful scope of [his or her] THEIR
 practice, who is licensed pursuant to article one hundred fifty-four  of
 the education law, a mental health counselor, marriage and family thera-
 pist,  or  psychoanalyst licensed pursuant to article one hundred sixty-
 three of the education law, a nurse practitioner licensed to practice in
 this state, or a professional corporation or university faculty practice
 corporation thereof, INCLUDING OUTPATIENT DRUG COVERAGE. Nothing  herein
 shall be construed to modify or expand the scope of practice of a mental
 health  counselor,  marriage  and  family  therapist,  or  psychoanalyst
 licensed pursuant to article one hundred sixty-three  of  the  education
 law. Further, nothing herein shall be construed to create a new mandated
 health benefit.
   (C)  Coverage  under this paragraph shall not apply financial require-
 ments or treatment limitations  to  mental  health  benefits,  INCLUDING
 OUTPATIENT DRUG COVERAGE, that are more restrictive than the predominant
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD09475-01-5
              

 S. 4867                             2
 
 financial requirements and treatment limitations applied to substantial-
 ly  all  medical  and  surgical benefits covered by the policy. COVERAGE
 UNDER THIS PARAGRAPH, INCLUDING DRUG COVERAGE, SHALL NOT  APPLY  ANY  OF
 THE  FOLLOWING TO A DRUG OR DRUGS PRESCRIBED FOR A SERIOUS MENTAL HEALTH
 CONDITION:
   (I) A FAIL-FIRST OR STEP THERAPY PROTOCOL, AS DEFINED BY SECTION  FOUR
 THOUSAND NINE HUNDRED OF THIS CHAPTER; OR
   (II)  A  PRIOR  AUTHORIZATION  REQUIREMENT, AS ESTABLISHED PURSUANT TO
 SUBSECTION (H) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS CHAP-
 TER.
   (E) For purposes of this paragraph:
   (i) "financial requirement" means deductible, copayments,  coinsurance
 and out-of-pocket expenses;
   (ii)  "predominant"  means  that  a financial requirement or treatment
 limitation is the most common or frequent  of  such  type  of  limit  or
 requirement;
   (iii)  "treatment  limitation" means limits on the frequency of treat-
 ment, number of visits, days of coverage, or other similar limits on the
 scope or duration of treatment and  includes  nonquantitative  treatment
 limitations  such as: medical management standards limiting or excluding
 benefits based on medical necessity, or based on whether  the  treatment
 is  experimental  or  investigational; formulary design for prescription
 drugs; network tier design; standards for provider admission to  partic-
 ipate in a network, including reimbursement rates; methods for determin-
 ing usual, customary, and reasonable charges; fail-first or step therapy
 protocols;  exclusions  based  on failure to complete a course of treat-
 ment; and restrictions based  on  geographic  location,  facility  type,
 provider  specialty, and other criteria that limit the scope or duration
 of benefits for services provided under the policy; [and]
   (iv) "mental health condition" means any  mental  health  disorder  as
 defined  in  the  most  recent edition of the diagnostic and statistical
 manual of mental disorders or the most recent edition of another  gener-
 ally recognized independent standard of current medical practice such as
 the international classification of diseases[.]; AND
   (V)  "SERIOUS  MENTAL  HEALTH  CONDITION"  MEANS  THE FOLLOWING MENTAL
 HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
 AND STATISTICAL MANUAL OF MENTAL DISORDERS:
   (I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
   (II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
   (III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
   (IV) OBSESSIVE-COMPULSIVE DISORDERS;
   (V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
   (VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
   (VII) SCHIZOPHRENIA.
   § 1-a. Items (vi) and (vii) of subparagraph (E)  of  paragraph  35  of
 subsection (i) of section 3216 of the insurance law, as added by section
 2 of subpart A of part II of chapter 57 of the laws of 2023, are amended
 and a new item (viii) is added to read as follows:
   (vi)  "critical time intervention services" means services rendered by
 a provider licensed under article thirty-one of the mental  hygiene  law
 that  provides  evidence-based,  therapeutic  interventions that include
 intensive outreach, engagement, and care coordination services that  are
 provided  to  an insured before the insured is discharged from inpatient
 care in a hospital as defined by subdivision ten of section 1.03 of  the
 mental  hygiene  law  or the emergency department of a hospital licensed
 S. 4867                             3
 
 pursuant to article twenty-eight of the public health law  and  continue
 after discharge until the insured is stabilized; [and]
   (vii)  "residential  facility"  means  crisis residence facilities and
 community residences for eating disorder integrated  treatment  programs
 licensed  pursuant  to  article thirty-one of the mental hygiene law[.];
 AND
   (VIII) "SERIOUS MENTAL HEALTH CONDITION" MEANS  THE  FOLLOWING  MENTAL
 HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
 AND STATISTICAL MANUAL OF MENTAL DISORDERS:
   (I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
   (II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
   (III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
   (IV) OBSESSIVE-COMPULSIVE DISORDERS;
   (V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
   (VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
   (VII) SCHIZOPHRENIA.
   §  2.  Item  (ii) of subparagraph (A) and subparagraphs (C) and (E) of
 paragraph 5 of subsection (l) of section 3221 of the insurance law, item
 (ii) of subparagraph (A) as amended by chapter 62 of the  laws  of  2023
 and  subparagraphs  (C)  and  (E) as added by section 14 of subpart A of
 part BB of chapter 57 of the laws   of   2019, are amended  to  read  as
 follows:
   (ii)  where  the  policy  provides coverage for physician services, it
 shall include benefits for outpatient care provided by a psychiatrist or
 psychologist licensed to practice in this  state,  or  a  mental  health
 counselor,  marriage  and  family  therapist,  or psychoanalyst licensed
 pursuant to article one hundred sixty-three of the education law,  or  a
 licensed  clinical social worker within the lawful scope of [his or her]
 THEIR practice, who is licensed pursuant to article one  hundred  fifty-
 four  of the education law, a nurse practitioner licensed to practice in
 this state, or a professional corporation or university faculty practice
 corporation thereof, INCLUDING OUTPATIENT DRUG COVERAGE.  Nothing herein
 shall be construed to modify or expand the scope of practice of a mental
 health  counselor,  marriage  and  family  therapist,  or  psychoanalyst
 licensed  pursuant  to  article one hundred sixty-three of the education
 law. Further, nothing herein shall be construed to create a new mandated
 health benefit.
   (C) Coverage under this paragraph shall not apply  financial  require-
 ments  or  treatment  limitations  to  mental health benefits, INCLUDING
 OUTPATIENT DRUG COVERAGE, that are more restrictive than the predominant
 financial requirements and treatment limitations applied to substantial-
 ly all medical and surgical benefits covered  by  the  policy.  COVERAGE
 UNDER  THIS  PARAGRAPH,  INCLUDING DRUG COVERAGE, SHALL NOT APPLY ANY OF
 THE FOLLOWING TO A DRUG OR DRUGS PRESCRIBED FOR A SERIOUS MENTAL  HEALTH
 CONDITION:
   (I)  A FAIL-FIRST OR STEP THERAPY PROTOCOL, AS DEFINED BY SECTION FOUR
 THOUSAND NINE HUNDRED OF THIS CHAPTER; OR
   (II) A PRIOR AUTHORIZATION REQUIREMENT,  AS  ESTABLISHED  PURSUANT  TO
 SUBSECTION (H) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS CHAP-
 TER.
   (E) For purposes of this paragraph:
   (i)  "financial requirement" means deductible, copayments, coinsurance
 and out-of-pocket expenses;
   (ii) "predominant" means that a  financial  requirement  or  treatment
 limitation  is  the  most  common  or  frequent of such type of limit or
 requirement;
 S. 4867                             4
 
   (iii) "treatment limitation" means limits on the frequency  of  treat-
 ment, number of visits, days of coverage, or other similar limits on the
 scope  or  duration  of treatment and includes nonquantitative treatment
 limitations such as: medical management standards limiting or  excluding
 benefits  based  on medical necessity, or based on whether the treatment
 is experimental or investigational; formulary  design  for  prescription
 drugs;  network tier design; standards for provider admission to partic-
 ipate in a network, including reimbursement rates; methods for determin-
 ing usual, customary, and reasonable charges; fail-first or step therapy
 protocols; exclusions based on failure to complete a  course  of  treat-
 ment;  and  restrictions  based  on  geographic location, facility type,
 provider specialty, and other criteria that limit the scope or  duration
 of benefits for services provided under the policy; [and]
   (iv)  "mental  health  condition"  means any mental health disorder as
 defined in the most recent edition of  the  diagnostic  and  statistical
 manual  of mental disorders or the most recent edition of another gener-
 ally recognized independent standard of current medical practice such as
 the international classification of diseases[.]; AND
   (V) "SERIOUS MENTAL  HEALTH  CONDITION"  MEANS  THE  FOLLOWING  MENTAL
 HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
 AND STATISTICAL MANUAL OF MENTAL DISORDERS:
   (I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
   (II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
   (III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
   (IV) OBSESSIVE-COMPULSIVE DISORDERS;
   (V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
   (VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
   (VII) SCHIZOPHRENIA.
   §  2-a.  Items  (vi)  and  (vii) of subparagraph (E) of paragraph 5 of
 subsection (l) of section 3221 of the insurance law, as added by section
 6 of subpart A of part II of chapter 57 of the laws of 2023, are amended
 and a new item (viii) is added to read as follows:
   (vi) "critical time intervention services" means services rendered  by
 a  provider  licensed under article thirty-one of the mental hygiene law
 that provides evidence-based,  therapeutic  interventions  that  include
 intensive  outreach, engagement, and care coordination services that are
 provided to an insured before the insured is discharged  from  inpatient
 care  in a hospital as defined by subdivision ten of section 1.03 of the
 mental hygiene law or the emergency department of  a  hospital  licensed
 pursuant  to  article twenty-eight of the public health law and continue
 after discharge until the insured is stabilized; [and]
   (vii) "residential facility" means  crisis  residence  facilities  and
 community  residences  for eating disorder integrated treatment programs
 licensed pursuant to article thirty-one of the  mental  hygiene  law[.];
 AND
   (VIII)  "SERIOUS  MENTAL  HEALTH CONDITION" MEANS THE FOLLOWING MENTAL
 HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
 AND STATISTICAL MANUAL OF MENTAL DISORDERS:
   (I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
   (II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
   (III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
   (IV) OBSESSIVE-COMPULSIVE DISORDERS;
   (V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
   (VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
   (VII) SCHIZOPHRENIA.
 S. 4867                             5
 
   § 3. Paragraphs 2, 4 and 6 of subsection (g) of section  4303  of  the
 insurance law, paragraph 2 as amended by chapter 62 of the laws of 2023,
 and paragraphs 4 and 6 as added by section 23 of subpart A of part BB of
 chapter 57 of the laws of 2019, are amended to read as follows:
   (2)  where  the contract provides coverage for physician services such
 contract shall provide  benefits  for  outpatient  care  provided  by  a
 psychiatrist  or  psychologist  licensed to practice in this state, or a
 mental health counselor, marriage and family therapist, or psychoanalyst
 licensed pursuant to article one hundred sixty-three  of  the  education
 law,  or  a  licensed  clinical social worker within the lawful scope of
 [his or her] THEIR practice, who is licensed  pursuant  to  article  one
 hundred  fifty-four  of the education law, a nurse practitioner licensed
 to practice in this state, or  professional  corporation  or  university
 faculty   practice   corporation   thereof,  INCLUDING  OUTPATIENT  DRUG
 COVERAGE. Nothing herein shall be construed  to  modify  or  expand  the
 scope  of  practice  of  a  mental health counselor, marriage and family
 therapist, or psychoanalyst licensed pursuant  to  article  one  hundred
 sixty-three  of  the  education  law.  Further,  nothing herein shall be
 construed to create a new mandated health benefit.
   (4) Coverage under this subsection shall not apply financial  require-
 ments  or  treatment  limitations  to  mental health benefits, INCLUDING
 OUTPATIENT DRUG COVERAGE, that are more restrictive than the predominant
 financial requirements and treatment limitations applied to substantial-
 ly all medical and surgical benefits covered by the  contract.  COVERAGE
 UNDER  THIS  PARAGRAPH,  INCLUDING DRUG COVERAGE, SHALL NOT APPLY ANY OF
 THE FOLLOWING TO A DRUG OR DRUGS PRESCRIBED FOR A SERIOUS MENTAL  HEALTH
 CONDITION:
   (I)  A FAIL-FIRST OR STEP THERAPY PROTOCOL, AS DEFINED BY SECTION FOUR
 THOUSAND NINE HUNDRED OF THIS CHAPTER; OR
   (II) A PRIOR AUTHORIZATION REQUIREMENT,  AS  ESTABLISHED  PURSUANT  TO
 SUBSECTION (H) OF SECTION FOUR THOUSAND NINE HUNDRED THREE OF THIS CHAP-
 TER.
   (6) For purposes of this subsection:
   (A)  "financial requirement" means deductible, copayments, coinsurance
 and out-of-pocket expenses;
   (B) "predominant" means that  a  financial  requirement  or  treatment
 limitation  is  the  most  common  or  frequent of such type of limit or
 requirement;
   (C) "treatment limitation" means limits on the frequency of treatment,
 number of visits, days of coverage, or other similar limits on the scope
 or duration of treatment and includes nonquantitative treatment  limita-
 tions  such as: medical management standards limiting or excluding bene-
 fits based on medical necessity, or based on whether  the  treatment  is
 experimental  or  investigational;  formulary  design  for  prescription
 drugs; network tier design; standards for provider admission to  partic-
 ipate in a network, including reimbursement rates; methods for determin-
 ing usual, customary, and reasonable charges; fail-first or step therapy
 protocols;  exclusions  based  on failure to complete a course of treat-
 ment; and restrictions based  on  geographic  location,  facility  type,
 provider  specialty, and other criteria that limit the scope or duration
 of benefits for services provided under the contract; [and]
   (D) "mental health condition" means  any  mental  health  disorder  as
 defined  in  the  most  recent edition of the diagnostic and statistical
 manual of mental disorders or the most recent edition of another  gener-
 ally recognized independent standard of current medical practice such as
 the international classification of diseases[.]; AND
 S. 4867                             6
 
   (E)  "SERIOUS  MENTAL  HEALTH  CONDITION"  MEANS  THE FOLLOWING MENTAL
 HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
 AND STATISTICAL MANUAL OF MENTAL DISORDERS:
   (I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
   (II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
   (III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
   (IV) OBSESSIVE-COMPULSIVE DISORDERS;
   (V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
   (VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
   (VII) SCHIZOPHRENIA.
   §  3-a.  Subparagraphs (F) and (G) of paragraph 6 of subsection (g) of
 section 4303 of the insurance law, as added by section 10 of  subpart  A
 of  part  II  of  chapter  57 of the laws of 2023, are amended and a new
 subparagraph (H) is added to read as follows:
   (F) "critical time intervention services" means services rendered by a
 provider licensed under article thirty-one of  the  mental  hygiene  law
 that  provides  evidence-based,  therapeutic  interventions that include
 intensive outreach, engagement, and care coordination services that  are
 provided  to  an insured before the insured is discharged from inpatient
 care in a hospital as defined by subdivision ten of section 1.03 of  the
 mental  hygiene  law  or the emergency department of a hospital licensed
 pursuant to article twenty-eight of the public health law  and  continue
 after discharge until the insured is stabilized; [and]
   (G)  "residential  facility"  means  crisis  residence  facilities and
 community residences for eating disorder integrated  treatment  programs
 licensed  pursuant  to  article thirty-one of the mental hygiene law[.];
 AND
   (H) "SERIOUS MENTAL  HEALTH  CONDITION"  MEANS  THE  FOLLOWING  MENTAL
 HEALTH DISORDERS AS DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC
 AND STATISTICAL MANUAL OF MENTAL DISORDERS:
   (I) BIPOLAR DISORDERS (HYPOMANIC, MANIC, DEPRESSIVE, AND MIXED);
   (II) DEPRESSION IN CHILDHOOD AND ADOLESCENCE;
   (III) MAJOR DEPRESSIVE DISORDERS (SINGLE EPISODE OR RECURRENT);
   (IV) OBSESSIVE-COMPULSIVE DISORDERS;
   (V) PARANOID AND OTHER PSYCHOTIC DISORDERS;
   (VI) SCHIZOAFFECTIVE DISORDERS (BIPOLAR OR DEPRESSIVE); AND
   (VII) SCHIZOPHRENIA.
   §  4. This act shall take effect on the first of January next succeed-
 ing the date on which it shall have become a law and shall apply to  all
 policies  and contracts issued, renewed, modified, altered or amended on
 or after such date; provided however, that if subpart A of  part  II  of
 chapter  57 of the laws of 2023 shall not have taken effect on or before
 such date then sections one-a, two-a and three-a of this act shall  take
 effect  on  the same date and in the same manner as such subpart of such
 part of such chapter of the laws of 2023 takes effect.