Requires health insurance to cover drug and alcohol abuse and dependency treatment services

Purpose

To ensure that patients suffering from drug and alcohol dependency receive appropriate care, by directing insurers to provide authorization and payment to appropriately licensed healthcare providers for detoxifi- cation, rehabilitation and intensive residential rehabilitation based on the examining physician's recommendation.

Summary of provisions

Section 1 adds a new paragraph (30) to subsection (i) of section 3216 of the Insurance Law to require every policy delivered or issued for deliv- ery in New York State which provides medical, major medical, or similar comprehensive-type coverage to include specific coverage for drug and alcohol abuse and dependency treatment services that are certified as necessary by a qualified health professional. The only prerequisite for the coverage of hospital-based detoxification is the certification and referral by a qualified health professional which will control both the nature and the duration of covered treatment, excepting when the attend- ing physician providing the drug and alcohol treatment certifies that admission of the covered person is not necessary, early discharge is appropriate, or additional days or sessions are necessary. The location of covered treatment is dependent on the insurer's requirements relating to the use of participating providers.

Section 2 adds a new paragraph (19) to subsection (1) of section 3221 of the Insurance Law. This section's language mirrors that of section 1, pertaining to every group or blanket policy delivered or issued for delivery in New York State.

Section 3 adds a new subsection (oo) to section 4303 of the Insurance law. This section's language again mirrors that of section 1, pertaining to every contract issued by a hospital service company or health service corporation.

Section 4 provides an effective date.

Justification

Prescription Drug Abuse is a public health crisis. During the 2011-12 Legislative Session the Senate Health Committee held two Roundtables on the subject and issued a report entitled "The Prescription Drug Crisis

in New York State: A Comprehensive Approach." In 2012 New York State took a bold step and adopted I-STOP (The Internet System for Tracking Over-Prescribing) which includes a number of provisions aimed at gaining better control over prescribing of controlled substances. At the same time, Nassau and Suffolk County each convened Task Forces on Prescription Drug Abuse. This legislation addresses concerns raised and recommendation that have been made to make sure patients whose health care provider feels that they need drug or alcohol addiction treatment are able to access those services from their insurer.

This legislation recognizes the important balance between insurers and providers in providing appropriate health care services. Many insurance companies rate healthcare providers based on the provider's ability to place patients into the appropriate level of care and contract with providers on this ability, as well as the provider's ability to deliver quality healthcare outcomes. Providers are not going to automatically start admitting everyone unnecessarily for several reasons: 1) there will be no capacity increase in this bill, limiting the number of avail- able beds to what they are at the present time; and 2) insurers can decide not to contract with providers who admit patients too readily, frequently or unnecessarily. In addition, with payment reform a part of the health care system overhaul and Affordable Care Act, providers have begun to take on the payment risk. By having arrangements with insurers to manage a population of beneficiaries and being paid a set amount for these managed lives, as opposed to on a fee-for-service basis, providers will make decisions based on what a patient needs, rather than on what they might get paid for a particular procedure. If a health care facili- ty admits patients unnecessarily, the dollars will soon be coming out of their pocket, NOT the insurance company.

A similar provision was adopted in the State of Pennsylvania in 1989 and has proven effective in ensuring appropriate treatment for those suffer- ing from alcohol and drug addiction. This legislation will provide a focus for New York to consider similar provisions. As New York's I-STOP law goes into effect, those currently addicted to prescription pain medication may find their sources dry up and seek treatment. This bill is an important next step to ensure those seeking treatment can access it.

Legislative history

New Bill.

Fiscal implications

To be determined.

Effective date

The first of January next succeeding the date on which it shall have become a law and shall apply to policies and contracts issued, renewed, modified, altered or amended on or after such date.