Department of Financial Services Issues Guidance to Insurers on Their Responsibilities in Addition to FAQs for Consumers to Understand Their Rights
New Requirements Improve Access to Treatment and Enhance Consumer Disclosures to Help Ensure New Yorkers Get the Assistance They Need
Governor Andrew M. Cuomo today detailed new requirements for health insurers that will mandate expanded coverage for New Yorkers seeking treatment for mental health conditions and addiction. In addition to new guidelines for insurers, the Department of Financial Services has issued a list of Frequently Asked Questions to help New Yorkers understand their rights under these new requirements. Consumers will be able to take advantage of these requirements starting on January 1, 2020.
"Every New Yorker deserves equal and affordable access to high quality health care, especially when it comes to mental health and addiction treatment services," Governor Cuomo said. "These new measures will help ensure people get the help they need and break down some of the most common barriers to treatment by limiting co-pays and educating consumers about the options available to them."
"We want to make sure that all New Yorkers, especially our most vulnerable, receive the health coverage and treatment they need," said Lieutenant Governor Kathy Hochul. "We are committed to expanding and supporting treatment services for individuals struggling with mental health conditions and addiction, and these new requirements will help to improve access and transparency when it comes to healthcare. Everyone should receive the care and support they need and deserve to live healthy and safe lives."
DFS issued guidance explaining insurers' new responsibilities regarding New Yorkers seeking treatment for mental health conditions and addiction. These responsibilities include improved consumer disclosures, limiting the amount of co-pays or coinsurance for outpatient mental health treatment and treatment for addiction, expanding existing protections related to medical necessity review of inpatient and outpatient treatment for addiction by health plans, and enacting new prohibitions on preauthorization requirements for certain inpatient mental health treatment.
DFS also issued guidance today advising insurers that they must cover costs associated with medically necessary peer support services as part of outpatient addiction treatment programs authorized by the Office of Addiction Services and Supports.
Department of Financial Services Superintendent Linda A. Lacewell said, "Building upon Governor Cuomo's leadership to build a stronger, healthier New York, DFS is issuing new requirements to help ensure that New Yorkers have affordable, equal access to treatment for mental health conditions and substance addiction disorder. The Department is committed to mental health and substance parity and we will make sure that all insurers adhere to statutory and regulatory requirements."
Department of Health Commissioner Dr. Howard Zucker said, "The continued expansion of access to health care under Governor Cuomo's leadership is improving the lives of all New Yorkers.These new requirements will help ensure that people seeking treatment for mental health conditions or addiction receive the services they need, without delay."
Office of Addiction Services and Supports Commissioner Arlene González-Sánchez said, "Many individuals struggling with addiction face too many obstacles to obtaining access to quality care. By implementing these new requirements, we are removing barriers and enabling better access to the comprehensive treatment needed to break the cycle of addiction to drugs, alcohol or other addictive substances."
Office of Mental Health Commissioner Dr. Ann Sullivan said, "Improving access to insurance coverage helps people living with mental illness get the services and treatment they need. The protections implemented by Governor Cuomo will require insurance plans to follow parity laws and provide access to appropriate coverage for treatment for addiction and mental health care."
New requirements related to addiction will:
- Prohibit preauthorization or concurrent review during the first 28 days of an inpatient admission for addiction treatment and during the first four weeks of outpatient treatment for addiction treatment;
- Require policies that cover prescription drugs for addiction treatment to provide immediate access to such drugs without prior authorization;
- Prohibit large group policies from imposing co-pays or coinsurance that exceed those of a primary care office visit for addiction treatment and limit co-pays to one co-pay per day for all services provided in a single day by addiction treatment facilities.
New requirements related to mental health conditions will:
- Require insurers and utilization review agents to use evidence-based and peer-reviewed clinical review criteria appropriate to the patient's age approved by the Commissioner of the Office of Mental Health in consultation with the Commissioner of Health and the Superintendent of Financial Services;
- Prohibit insurers from imposing co-pays or coinsurance for outpatient mental health treatment in authorized facilities that exceeds those of a primary care office visit;
- Prohibit preauthorization or concurrent review during the first 14 days of an inpatient admission for treatment of a mental health condition for patients under age 18;
- Ensure clinical peer reviewers have experience in delivering mental health treatment.
New requirements also update New York law to:
- Require insurers to provide consumers the most recent comparative analysis performed to assess the provision of covered services in accordance with the Mental Health Parity and Addiction Equity Act of 2008.
DFS will be prepared to investigate insurers' compliance with the new requirements, including market conduct examinations.
A full copy of the guidance letter for health insurance coverage for mental health conditions and treatment for addiction can be found here.
A full copy of the guidance letter for health insurance coverage for peer support services can be found here.