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New health-insurance mandates for mental health & addiction coverage take effect

The Business Journal - 1/18/2020

Health insurers are facing new mandates for expanded insurance coverage for New Yorkers seeking treatment for mental-health conditions and addiction.

In addition to new guidelines for insurers, the New York State Department of Financial Services (DFS) has issued a list of frequently asked questions to help New Yorkers understand their rights under these new requirements, which went into effect on Jan. 1, 2020, the office of Gov. Andrew Cuomo announced.

"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," Cuomo said in a statement.

DFS issued guidance explaining insurers' new responsibilities regarding New Yorkers seeking treatment for mental-health conditions and addiction. These mandates 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 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.

Addiction mandates

New requirements related to addiction prohibit preauthorization or concurrent review during the first 28 days of an in-patient admission for addiction treatment and during the first four weeks of outpatient treatment for addiction treatment.

They also require policies that cover treatment. They also limit co-pays to one co-pay per day for all services provided in a single day by addiction-treatment facilities.

Mental-health condition requirements

New mandates related to mental-health conditions have insurers and utilization-review agents using evidence-based and peer-reviewed clinical-review criteria appropriate to the patient's age. The criteria is also approved by the commissioner of the Office of Mental Health in consultation with the commissioner of Health and the Superintendent of Financial Services.

The new requirements also 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.

They also 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.

In addition, they ensure clinical peer reviewers have experience in delivering mental-health treatment.

Updating New York law

New requirements also update New York law to have insurers 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 says it will be prepared to investigate insurers' compliance with the new requirements, including market-conduct examinations.