Guidance Issued by DFS to Insurance Companies Outlines New Coverage Requirements
Follows Landmark Legislation Signed by the Governor to Combat Opioid Abuse
Governor Andrew M. Cuomo today announced that the Department of Financial Services has issued guidance to health insurers outlining new insurance coverage requirements for substance abuse treatment. The action follows landmark legislation signed by the Governor earlier this year to combat the heroin and opioid crisis in New York State.
Under the new law, health insurers will be required to cover medication, including naloxone, for detoxification or maintenance treatment of substance use disorders under large group policies. This new requirement mirrors the coverage requirements for individual and small group policies. Health insurers will also be required to provide coverage without preauthorization for inpatient substance abuse treatment in facilities that participate in their networks and are certified by the New York State Office of Alcoholism and Substance Abuse Services.
“Health insurers have an obligation to cover costs for lifesaving substance abuse treatment and our administration will have zero tolerance for those who seek to sidestep this responsibility,” Governor Cuomo said. “This action is an important step toward breaking the cycle of addiction and ending the epidemic of opioid abuse once and for all.”
Maria T. Vullo, Superintendent of Financial Services, said, “The guidance issued today outlines the specific requirements insurers must satisfy, and DFS will enforce, to ensure that New Yorkers suffering from opioid abuse receive the kinds of treatment, such as inpatient and outpatient coverage for detoxification, that are essential for recovery so that they can rebuild their lives.”
The new guidance issued today alerts health insurers that they must provide inpatient and outpatient coverage for detoxification and maintenance treatment medication, including naloxone. It also instructs health insurers that they must eliminate prior authorization requirements for a five-day emergency supply of prescribed medications for the treatment of substance use disorder when an emergency arises. The guidance by DFS outlines insurer utilization review requirements, and includes timeframes under which the utilization review determinations must be made by health insurers.
The landmark legislation signed by Governor Cuomo was a comprehensive package of bills passed as part of the 2016 Legislative Session. The measures marked a major step forward in the fight to expand access to treatment and community prevention strategies, as well as to limit the over-prescription of opioids. The legislation included best practices and recommendations identified by the Governor’s Heroin and Opioid Task Force, of which DFS Superintendent Vullo is a member, which built on the state’s aggressive efforts to break the cycle of heroin and opioid addiction and protect public health and safety.
DFS will review health insurers’ compliance with requirements for coverage during market conduct exams and will take action against any insurers found to have failed to meet all statutory and regulatory requirements for coverage of substance use disorder treatment.
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