N.Y. Insurance Law § 343: Mental health and substance use disorder parity report

* § 343. Mental health and substance use disorder parity report. (a)

Beginning July first, two thousand nineteen and every two years

thereafter, each insurer providing managed care products, individual

comprehensive accident and health insurance or group or blanket

comprehensive accident and health insurance, each corporation organized

pursuant to article forty-three of this chapter providing comprehensive

health insurance and each entity licensed pursuant to article forty-four

of the public health law providing comprehensive health service plans

shall submit to the superintendent, in a form and manner prescribed by

the superintendent, a report detailing the entity's compliance with

federal and state mental health and substance use disorder parity laws

based on the entity's record during the preceding two calendar years.

The superintendent shall publish on the department's website on or

before October first, two thousand nineteen, and every two years

thereafter, the reports submitted pursuant to this section.

(b) Each person required to submit a report under this section shall

include in the report the following information:

(1) 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: inpatient in-network, inpatient

out-of-network, outpatient in-network, outpatient out-of-network,

emergency care, and prescription drugs;

(2) 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 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

determinations 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

services and substance use disorder services compared with the

percentage of claims paid for out-of-network medical and surgical

services;

(5) The number of behavioral health advocates, pursuant to an

agreement 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

including limitations on the scope and duration of coverage, for medical

and surgical services, and mental health services and substance use

disorder services for coverage in the individual, small group, and large

group markets, provided that the comparison captures at least

seventy-five percent of a company's enrollees in each market;

(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

diagnosis 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

providers, and the percentage of providers of services for the diagnosis

and treatment of mental, nervous or emotional disorders and ailments,

however defined in a company's policy, who remained participating

providers; and

(9) Any other data, information, or metric the superintendent deems

necessary or useful 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 reimbursement 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.

* NB Effective until January 1, 2027

* § 343. Mental health and substance-related and addictive disorder

services parity report. (a) Beginning July first, two thousand nineteen

and every two years thereafter, each insurer providing managed care

products, individual comprehensive accident and health insurance or

group or blanket comprehensive accident and health insurance, each

corporation organized pursuant to article forty-three of this chapter

providing comprehensive health insurance and each entity licensed

pursuant to article forty-four of the public health law providing

comprehensive health service plans shall submit to the superintendent,

in a form and manner prescribed by the superintendent, a report

detailing the entity's compliance with federal and state mental health

and substance-related and addictive disorder services parity laws based

on the entity's record during the preceding two calendar years. The

superintendent shall publish on the department's website on or before

October first, two thousand nineteen, and every two years thereafter,

the reports submitted pursuant to this section.

(b) Each person required to submit a report under this section shall

include in the report the following information:

(1) Rates of utilization review for mental health and

substance-related and addictive disorder claims as compared to medical

and surgical claims, including rates of approval and denial, categorized

by benefits provided under the following classifications: inpatient

in-network, inpatient out-of-network, outpatient in-network, outpatient

out-of-network, emergency care, and prescription drugs;

(2) The number of prior or concurrent authorization requests for

mental health services and for substance-related and addictive 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 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-related and addictive disorder claims compared with

the rates of appeals of adverse determinations, including the rates of

adverse determinations upheld and overturned, for medical and surgical

claims;

(4) The percentage of claims paid for in-network mental health

services and for substance-related and addictive 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 services and substance-related and addictive disorder

services compared with the percentage of claims paid for out-of-network

medical and surgical services;

(5) The number of behavioral health advocates, pursuant to an

agreement with the office of the attorney general if applicable, or

staff available to assist policyholders with mental health benefits and

substance-related and addictive disorder benefits;

(6) A comparison of the cost sharing requirements including but not

limited to co-pays and coinsurance, and the benefit limitations

including limitations on the scope and duration of coverage, for medical

and surgical services, and mental health services and substance-related

and addictive disorder services for coverage in the individual, small

group, and large group markets, provided that the comparison captures at

least seventy-five percent of a company's enrollees in each market;

(7) The number by type of providers licensed to practice in this state

that provide services for the treatment and diagnosis of

substance-related and addictive disorder who are in-network, and the

number by type of providers licensed to practice in this state that

provide services for the diagnosis 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-related and addictive disorder who remained

participating providers, and the percentage of providers of services for

the diagnosis and treatment of mental, nervous or emotional disorders

and ailments, however defined in a company's policy, who remained

participating providers; and

(9) Any other data, information, or metric the superintendent deems

necessary or useful to measure compliance with mental health and

substance-related and addictive 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-related and

addictive disorder provider panels pursuant to provisions of the

insurance law and public health law; and (ii) the company's

reimbursement for in-network and out-of-network mental health services

and substance-related and addictive disorder services as compared to the

reimbursement for in-network and out-of-network medical and surgical

services.

* NB Effective January 1, 2027