STATE OF NEW YORK ________________________________________________________________________ 5300 2023-2024 Regular Sessions IN SENATE March 1, 2023 ___________ Introduced by Sen. FERNANDEZ -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law, in relation to providing behavioral health parity (Part A); and to amend the insurance law, in relation to the authorization for certain drugs for the detoxification or mainte- nance of a substance use disorder (Part B) The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. This act enacts into law components of legislation which 2 are necessary to effectuate provisions relating to mental health and 3 substance use disorder parity. Each component is wholly contained with- 4 in a Part identified as Parts A through B. The effective date for each 5 particular provision contained within such Part is set forth in the last 6 section of such Part. Any provision in any section contained within a 7 Part, including the effective date of the Part, which makes reference 8 to a section "of this act", when used in connection with that partic- 9 ular component, shall be deemed to mean and refer to the correspond- 10 ing section of the Part in which it is found. Section three of this act 11 sets forth the general effective date of this act. 12 PART A 13 Section 1. Subparagraph (D) of paragraph 30 of subsection (i) of 14 section 3216 of the insurance law, as amended by section 5 of subpart A 15 of part BB of chapter 57 of the laws of 2019, is amended to read as 16 follows: 17 (D) This subparagraph shall apply to facilities in this state that are 18 licensed, certified or otherwise authorized by the office of [~~alcoholism~~ 19 ~~and substance abuse services~~] addiction services and supports that are 20 participating in the insurer's provider network. Coverage provided under 21 this paragraph shall not be subject to preauthorization. Coverage EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD03088-01-3

S. 5300 2 1 provided under this paragraph shall also not be subject to concurrent 2 utilization review during the first twenty-eight days of the inpatient 3 admission provided that the facility notifies the insurer of both the 4 admission and the initial treatment plan within two business days of the 5 admission on a standardized form developed by the department in consul- 6 tation with the department of health and the office of addiction 7 services and supports. The facility shall perform daily clinical review 8 of the patient[~~, including periodic~~] and consult periodically with the 9 insurer regarding the patient's progress, course of treatment, and 10 discharge plan. Periodic consultation with the insurer [~~at or just prior~~ 11 to] shall occur no later than the fourteenth day of treatment [~~to ensure~~ 12 ~~that the facility is using the evidence-based and peer reviewed clinical~~ 13 ~~review tool utilized by the insurer which is designated by the office of~~ 14 ~~alcoholism and substance abuse services and appropriate to the age of~~ 15 ~~the patient, to ensure that the inpatient treatment is medically neces-~~ 16 ~~sary for the patient~~]. Prior to discharge, the facility shall provide 17 the patient and the insurer with a written discharge plan which shall 18 describe arrangements for additional services needed following discharge 19 from the inpatient facility as determined using the evidence-based and 20 peer-reviewed clinical review tool utilized by the insurer which is 21 designated by the office of [~~alcoholism and substance abuse services~~] 22 addiction services and supports. Prior to discharge, the facility shall 23 indicate to the insurer whether services included in the discharge plan 24 are secured or determined to be reasonably available. [~~Any~~] Insurers 25 shall actively participate in facility-initiated periodic consultations 26 prior to the patient's discharge and except where the insurer fails to 27 do so, any utilization review of treatment provided under this subpara- 28 graph may include a review of all services provided during such inpa- 29 tient treatment, including all services provided during the first twen- 30 ty-eight days of such inpatient treatment. Provided, however, the 31 insurer shall be required to process claims for the provision of such 32 services within the timeframes established in subsection (a) of section 33 three thousand two hundred twenty-four-a of this article and shall only 34 deny coverage for any portion of the initial twenty-eight day inpatient 35 treatment on the basis that such treatment was not medically necessary 36 if such inpatient treatment was contrary to the evidence-based and peer 37 reviewed clinical review tool utilized by the insurer which is desig- 38 nated by the office of [~~alcoholism and substance abuse services~~] 39 addiction services and supports. An insured shall not have any financial 40 obligation to the facility for any treatment under this subparagraph 41 other than any copayment, coinsurance, or deductible otherwise required 42 under the policy. 43 § 2. Subparagraph (E) of paragraph 31 of subsection (i) of section 44 3216 of the insurance law, as amended by section 6 of subpart A of part 45 BB of chapter 57 of the laws of 2019, is amended to read as follows: 46 (E) This subparagraph shall apply to facilities in this state that are 47 licensed, certified or otherwise authorized by the office of [~~alcoholism~~ 48 ~~and substance abuse services~~] addiction services and supports for the 49 provision of outpatient, intensive outpatient, outpatient rehabilitation 50 and opioid treatment that are participating in the insurer's provider 51 network. Coverage provided under this paragraph shall not be subject to 52 preauthorization. Coverage provided under this paragraph shall not be 53 subject to concurrent review for the first four weeks of continuous 54 treatment, not to exceed twenty-eight visits, provided the facility 55 notifies the insurer of both the start of treatment and the initial 56 treatment plan within two business days on a standardized form developed

S. 5300 3 1 by the department in consultation with the department of health and the 2 office of addiction services and supports. The facility shall perform 3 clinical assessment of the patient at each visit[~~, including periodic~~] 4 and consult periodically with the insurer regarding the patient's 5 progress, course of treatment, and discharge plan. Periodic consultation 6 with the insurer [~~at or just prior to~~] shall occur no later than the 7 fourteenth day of treatment [~~to ensure that the facility is using the~~ 8 ~~evidence-based and peer reviewed clinical review tool utilized by the~~ 9 ~~insurer which is designated by the office of alcoholism and substance~~ 10 ~~abuse services and appropriate to the age of the patient, to ensure that~~ 11 ~~the outpatient treatment is medically necessary for the patient~~]. [~~Any~~] 12 Insurers shall actively participate in facility-initiated periodic 13 consultations prior to the patient's discharge and except where the 14 insurer fails to do so, any utilization review of the treatment provided 15 under this subparagraph may include a review of all services provided 16 during such outpatient treatment, including all services provided during 17 the first four weeks of continuous treatment, not to exceed twenty-eight 18 visits, of such outpatient treatment. Provided, however, the insurer 19 shall only deny coverage for any portion of the initial four weeks of 20 continuous treatment, not to exceed twenty-eight visits, for outpatient 21 treatment on the basis that such treatment was not medically necessary 22 if such outpatient treatment was contrary to the evidence-based and peer 23 reviewed clinical review tool utilized by the insurer which is desig- 24 nated by the office of [~~alcoholism and substance abuse services~~] 25 addiction services and supports. An insured shall not have any finan- 26 cial obligation to the facility for any treatment under this subpara- 27 graph other than any copayment, coinsurance, or deductible otherwise 28 required under the policy. 29 § 3. Subparagraph (G) of paragraph 35 of subsection (i) of section 30 3216 of the insurance law, as added by section 8 of subpart A of part BB 31 of chapter 57 of the laws of 2019, is amended to read as follows: 32 (G) This subparagraph shall apply to hospitals in this state that are 33 licensed, certified or otherwise authorized by the office of mental 34 health that are participating in the insurer's provider network. Where 35 the policy provides coverage for inpatient hospital care, benefits for 36 inpatient hospital care in a hospital as defined by subdivision ten of 37 section 1.03 of the mental hygiene law [~~provided to individuals who have~~ 38 ~~not attained the age of eighteen~~] shall not be subject to preauthori- 39 zation. Coverage provided under this subparagraph shall also not be 40 subject to concurrent utilization review during the first fourteen days 41 of the inpatient admission, provided the facility notifies the insurer 42 of both the admission and the initial treatment plan within two business 43 days of the admission on a standardized form developed by the department 44 in consultation with the department of health and the office of mental 45 health, performs daily clinical review of the patient, and [~~participates~~ 46 ~~in periodic consultation with the insurer to ensure that the facility is~~ 47 ~~using the evidence-based and peer reviewed clinical review criteria~~ 48 ~~utilized by the insurer which is approved by the office of mental health~~ 49 ~~and appropriate to the age of the patient, to ensure that the inpatient~~ 50 ~~care is medically necessary for the patient~~] consults periodically with 51 the insurer regarding the patient's progress, course of treatment, and 52 discharge plan. [~~All~~] Insurers shall actively participate in facility- 53 initiated periodic consultations prior to the patient's discharge and 54 except where the insurer fails to do so, all treatment provided under 55 this subparagraph may be reviewed retrospectively. Where care is denied 56 retrospectively, an insured shall not have any financial obligation to

S. 5300 4 1 the facility for any treatment under this subparagraph other than any 2 copayment, coinsurance, or deductible otherwise required under the poli- 3 cy. 4 § 4. Subparagraph (G) of paragraph 5 of subsection (l) of section 3221 5 of the insurance law, as added by section 14 of subpart A of part BB of 6 chapter 57 of the laws of 2019, is amended to read as follows: 7 (G) This subparagraph shall apply to hospitals in this state that are 8 licensed, certified or otherwise authorized by the office of mental 9 health that are participating in the insurer's provider network. Where 10 the policy provides coverage for inpatient hospital care, benefits for 11 inpatient hospital care in a hospital as defined by subdivision ten of 12 section 1.03 of the mental hygiene law [~~provided to individuals who have~~ 13 ~~not attained the age of eighteen~~] shall not be subject to preauthori- 14 zation. Coverage provided under this subparagraph shall also not be 15 subject to concurrent utilization review during the first fourteen days 16 of the inpatient admission, provided the facility notifies the insurer 17 of both the admission and the initial treatment plan within two business 18 days of the admission on a standardized form developed by the department 19 in consultation with the department of health and the office of mental 20 health, performs daily clinical review of the patient, and [~~participates~~ 21 ~~in periodic consultation with the insurer to ensure that the facility is~~ 22 ~~using the evidence-based and peer reviewed clinical review criteria~~ 23 ~~utilized by the insurer which is approved by the office of mental health~~ 24 ~~and appropriate to the age of the patient, to ensure that the inpatient~~ 25 ~~care is medically necessary for the patient~~] consults periodically with 26 the insurer regarding the patient's progress, course of treatment, and 27 discharge plan. [~~All~~] Insurers shall actively participate in facility- 28 initiated periodic consultations prior to the patient's discharge and 29 except where the insurer fails to do so, all treatment provided under 30 this subparagraph may be reviewed retrospectively. Where care is denied 31 retrospectively, an insured shall not have any financial obligation to 32 the facility for any treatment under this subparagraph other than any 33 copayment, coinsurance, or deductible otherwise required under the poli- 34 cy. 35 § 5. Subparagraph (D) of paragraph 6 of subsection (l) of section 3221 36 of the insurance law, as amended by section 15 of subpart A of part BB 37 of chapter 57 of the laws of 2019, is amended to read as follows: 38 (D) This subparagraph shall apply to facilities in this state that are 39 licensed, certified or otherwise authorized by the office of [~~alcoholism~~ 40 ~~and substance abuse services~~] addiction services and supports that are 41 participating in the insurer's provider network. Coverage provided under 42 this paragraph shall not be subject to preauthorization. Coverage 43 provided under this paragraph shall also not be subject to concurrent 44 utilization review during the first twenty-eight days of the inpatient 45 admission provided that the facility notifies the insurer of both the 46 admission and the initial treatment plan within two business days of the 47 admission on a standardized form developed by the department in consul- 48 tation with the department of health and the office of addiction 49 services and supports. The facility shall perform daily clinical review 50 of the patient[~~, including periodic~~] and consult periodically with the 51 insurer regarding the patient's progress, course of treatment, and 52 discharge plan. Periodic consultation with the insurer [~~at or just prior~~ 53 to] shall occur no later than the fourteenth day of treatment [~~to ensure~~ 54 ~~that the facility is using the evidence-based and peer reviewed clinical~~ 55 ~~review tool utilized by the insurer which is designated by the office of~~ 56 ~~alcoholism and substance abuse services and appropriate to the age of~~

S. 5300 5 1 ~~the patient, to ensure that the inpatient treatment is medically neces-~~ 2 ~~sary for the patient~~]. Prior to discharge, the facility shall provide 3 the patient and the insurer with a written discharge plan which shall 4 describe arrangements for additional services needed following discharge 5 from the inpatient facility as determined using the evidence-based and 6 peer-reviewed clinical review tool utilized by the insurer which is 7 designated by the office of [~~alcoholism and substance abuse services~~] 8 addiction services and supports. Prior to discharge, the facility shall 9 indicate to the insurer whether services included in the discharge plan 10 are secured or determined to be reasonably available. [~~Any~~] Insurers 11 shall actively participate in facility-initiated periodic consultations 12 prior to the patient's discharge and except where the insurer fails to 13 do so, any utilization review of treatment provided under this subpara- 14 graph may include a review of all services provided during such inpa- 15 tient treatment, including all services provided during the first twen- 16 ty-eight days of such inpatient treatment. Provided, however, the 17 insurer shall be required to process claims for the provision of such 18 services within the timeframes established in subsection (a) of section 19 three thousand two hundred twenty-four-a of this article and shall only 20 deny coverage for any portion of the initial twenty-eight day inpatient 21 treatment on the basis that such treatment was not medically necessary 22 if such inpatient treatment was contrary to the evidence-based and peer 23 reviewed clinical review tool utilized by the insurer which is desig- 24 nated by the office of [~~alcoholism and substance abuse services~~] 25 addiction services and supports. An insured shall not have any financial 26 obligation to the facility for any treatment under this subparagraph 27 other than any copayment, coinsurance, or deductible otherwise required 28 under the policy. 29 § 6. Subparagraph (E) of paragraph 7 of subsection (l) of section 3221 30 of the insurance law, as amended by section 17 of subpart A of part BB 31 of chapter 57 of the laws of 2019, is amended to read as follows: 32 (E) This subparagraph shall apply to facilities in this state that are 33 licensed, certified or otherwise authorized by the office of [~~alcoholism~~ 34 ~~and substance abuse services~~] addiction services and supports for the 35 provision of outpatient, intensive outpatient, outpatient rehabilitation 36 and opioid treatment that are participating in the insurer's provider 37 network. Coverage provided under this paragraph shall not be subject to 38 preauthorization. Coverage provided under this paragraph shall not be 39 subject to concurrent review for the first four weeks of continuous 40 treatment, not to exceed twenty-eight visits, provided the facility 41 notifies the insurer of both the start of treatment and the initial 42 treatment plan within two business days on a standardized form developed 43 by the department in consultation with the department of health and the 44 office of addiction services and supports. The facility shall perform 45 clinical assessment of the patient at each visit[~~, including periodic~~] 46 and consult periodically with the insurer regarding the patient's 47 progress, course of treatment, and discharge plan. Periodic consultation 48 with the insurer [~~at or just prior to~~] shall occur no later than the 49 fourteenth day of treatment [~~to ensure that the facility is using the~~ 50 ~~evidence-based and peer reviewed clinical review tool utilized by the~~ 51 ~~insurer which is designated by the office of alcoholism and substance~~ 52 ~~abuse services and appropriate to the age of the patient, to ensure that~~ 53 ~~the outpatient treatment is medically necessary for the patient~~]. [~~Any~~] 54 Insurers shall actively participate in facility-initiated periodic 55 consultations prior to the patient's discharge and except where the 56 insurer fails to do so, any utilization review of the treatment provided

S. 5300 6 1 under this subparagraph may include a review of all services provided 2 during such outpatient treatment, including all services provided during 3 the first four weeks of continuous treatment, not to exceed twenty-eight 4 visits, of such outpatient treatment. Provided, however, the insurer 5 shall only deny coverage for any portion of the initial four weeks of 6 continuous treatment, not to exceed twenty-eight visits, for outpatient 7 treatment on the basis that such treatment was not medically necessary 8 if such outpatient treatment was contrary to the evidence-based and peer 9 reviewed clinical review tool utilized by the insurer which is desig- 10 nated by the office of [~~alcoholism and substance abuse services~~] 11 addiction services and supports. An insured shall not have any finan- 12 cial obligation to the facility for any treatment under this subpara- 13 graph other than any copayment, coinsurance, or deductible otherwise 14 required under the policy. 15 § 7. Subsection (a) of section 3224-a of the insurance law, as amended 16 by chapter 237 of the laws of 2009, is amended to read as follows: 17 (a) Except in a case where the obligation of an insurer or an organ- 18 ization or corporation licensed or certified pursuant to article forty- 19 three or forty-seven of this chapter or article forty-four of the public 20 health law to pay a claim submitted by a policyholder or person covered 21 under such policy ("covered person") or make a payment to a health care 22 provider is not reasonably clear, or when there is a reasonable basis 23 supported by specific information available for review by the super- 24 intendent that such claim or bill for health care services rendered was 25 submitted fraudulently, such insurer or organization or corporation 26 shall pay the claim to a policyholder or covered person or make a 27 payment to a health care provider within thirty days of receipt of a 28 claim or bill for services rendered that is transmitted via the internet 29 or electronic mail, or forty-five days of receipt of a claim or bill for 30 services rendered that is submitted by other means, such as paper or 31 facsimile. The obligation of an insurer or organization to make payment 32 to a health care provider for mental health or substance use disorder 33 services that are not subject to preauthorization or concurrent review 34 pursuant to sections three thousand two hundred sixteen, three thousand 35 two hundred twenty-one, or four thousand three hundred three of this 36 chapter shall not be considered not reasonably clear solely because the 37 insurer or organization intends to perform concurrent review for such 38 services before or after the expiration of the timeframes established by 39 this subsection. 40 § 8. Paragraph 8 of subsection (g) of section 4303 of the insurance 41 law, as added by section 23 of subpart A of part BB of chapter 57 of the 42 laws of 2019, is amended to read as follows: 43 (8) This paragraph shall apply to hospitals in this state that are 44 licensed, certified or otherwise authorized by the office of mental 45 health that are participating in the [~~corporation's~~] insurer's provider 46 network. Where the contract provides coverage for inpatient hospital 47 care, benefits for inpatient hospital care in a hospital as defined by 48 subdivision ten of section 1.03 of the mental hygiene law [~~provided to~~ 49 ~~individuals who have not attained the age of eighteen~~] shall not be 50 subject to preauthorization. Coverage provided under this paragraph 51 shall also not be subject to concurrent utilization review during the 52 first fourteen days of the inpatient admission, provided the facility 53 notifies the [~~corporation~~] insurer of both the admission and the initial 54 treatment plan within two business days of the admission on a standard- 55 ized form developed by the department in consultation with the depart- 56 ment of health and the office of mental health, performs daily clinical

S. 5300 7 1 review of the patient, and [~~participates in periodic consultation with~~ 2 ~~the corporation to ensure that the facility is using the evidence-based~~ 3 ~~and peer reviewed clinical review criteria utilized by the corporation~~ 4 ~~which is approved by the office of mental health and appropriate to the~~ 5 ~~age of the patient, to ensure that the inpatient care is medically~~ 6 ~~necessary for the patient~~] consults periodically with the insurer 7 regarding the patient's progress, course of treatment, and discharge 8 plan. [~~All~~] Insurers shall actively participate in facility-initiated 9 periodic consultations prior to the patient's discharge and except where 10 the insurer fails to do so, all treatment provided under this paragraph 11 may be reviewed retrospectively. Where care is denied retrospectively, 12 an insured shall not have any financial obligation to the facility for 13 any treatment under this paragraph other than any copayment, coinsu- 14 rance, or deductible otherwise required under the contract. 15 § 9. Paragraph 4 of subsection (k) of section 4303 of the insurance 16 law, as amended by section 26 of subpart A of part BB of chapter 57 of 17 the laws of 2019, is amended to read as follows: 18 (4) This paragraph shall apply to facilities in this state that are 19 licensed, certified or otherwise authorized by the office of [~~alcoholism~~ 20 ~~and substance abuse services~~] addiction services and supports that are 21 participating in the [~~corporation's~~] insurer's provider network. Cover- 22 age provided under this subsection shall not be subject to preauthori- 23 zation. Coverage provided under this subsection shall also not be 24 subject to concurrent utilization review during the first twenty-eight 25 days of the inpatient admission provided that the facility notifies the 26 [~~corporation~~] insurer of both the admission and the initial treatment 27 plan within two business days of the admission on a standardized form 28 developed by the department in consultation with the department of 29 health and the office of addiction services and supports. The facility 30 shall perform daily clinical review of the patient[~~, including periodic~~ 31 ~~consultation~~] and consult periodically with the insurer regarding the 32 patient's progress, course of treatment, and discharge plan. Periodic 33 consultation with the [~~corporation at or just prior to~~] insurer shall 34 occur not later than the fourteenth day of treatment [~~to ensure that the~~ 35 ~~facility is using the evidence-based and peer reviewed clinical review~~ 36 ~~tool utilized by the corporation which is designated by the office of~~ 37 ~~alcoholism and substance abuse services and appropriate to the age of~~ 38 ~~the patient, to ensure that the inpatient treatment is medically neces-~~ 39 ~~sary for the patient~~]. Prior to discharge, the facility shall provide 40 the patient and the [~~corporation~~] insurer with a written discharge plan 41 which shall describe arrangements for additional services needed follow- 42 ing discharge from the inpatient facility as determined using the 43 evidence-based and peer-reviewed clinical review tool utilized by the 44 [~~corporation~~] insurer which is designated by the office of [~~alcoholism~~ 45 ~~and substance abuse services~~] addiction services and supports. Prior to 46 discharge, the facility shall indicate to the [~~corporation~~] insurer 47 whether services included in the discharge plan are secured or deter- 48 mined to be reasonably available. [~~Any~~] Insurers shall actively partic- 49 ipate in facility-initiated periodic consultations prior to the 50 patient's discharge and except where the insurer fails to do so, any 51 utilization review of treatment provided under this paragraph may 52 include a review of all services provided during such inpatient treat- 53 ment, including all services provided during the first twenty-eight days 54 of such inpatient treatment. Provided, however, the [~~corporation~~] insur- 55 er shall be required to process claims for the provision of such 56 services within the timeframes established in subsection (a) of section

S. 5300 8 1 three thousand two hundred twenty-four-a of this chapter and shall only 2 deny coverage for any portion of the initial twenty-eight day inpatient 3 treatment on the basis that such treatment was not medically necessary 4 if such inpatient treatment was contrary to the evidence-based and peer 5 reviewed clinical review tool utilized by the [~~corporation~~] insurer 6 which is designated by the office of [~~alcoholism and substance abuse~~ 7 ~~services~~] addiction services and supports. An insured shall not have 8 any financial obligation to the facility for any treatment under this 9 paragraph other than any copayment, coinsurance, or deductible otherwise 10 required under the contract. 11 § 10. Paragraph 5 of subsection (l) of section 4303 of the insurance 12 law, as amended by section 28 of subpart A of part BB of chapter 57 of 13 the laws of 2019, is amended to read as follows: 14 (5) This paragraph shall apply to facilities in this state that are 15 licensed, certified or otherwise authorized by the office of [~~alcoholism~~ 16 ~~and substance abuse services~~] addiction services and supports for the 17 provision of outpatient, intensive outpatient, outpatient rehabilitation 18 and opioid treatment that are participating in the corporation's provid- 19 er network. Coverage provided under this subsection shall not be subject 20 to preauthorization. Coverage provided under this subsection shall not 21 be subject to concurrent review for the first four weeks of continuous 22 treatment, not to exceed twenty-eight visits, provided the facility 23 notifies the corporation of both the start of treatment and the initial 24 treatment plan within two business days on a standardized form developed 25 by the department in consultation with the department of health and the 26 office of addiction services and supports. The facility shall perform 27 clinical assessment of the patient at each visit[~~, including periodic~~] 28 and consult periodically with the insurer regarding the patient's 29 progress, course of treatment, and discharge plan. Periodic consultation 30 with the corporation [~~at or just prior to~~] shall occur no later than the 31 fourteenth day of treatment [~~to ensure that the facility is using the~~ 32 ~~evidence-based and peer reviewed clinical review tool utilized by the~~ 33 ~~corporation which is designated by the office of alcoholism and~~ 34 ~~substance abuse services and appropriate to the age of the patient, to~~ 35 ~~ensure that the outpatient treatment is medically necessary for the~~ 36 ~~patient~~]. [~~Any~~] Insurers shall actively participate in facility-initiat- 37 ed periodic consultations prior to the patient's discharge and except 38 where the insurer fails to do so, any utilization review of the treat- 39 ment provided under this paragraph may include a review of all services 40 provided during such outpatient treatment, including all services 41 provided during the first four weeks of continuous treatment, not to 42 exceed twenty-eight visits, of such outpatient treatment. Provided, 43 however, the corporation shall only deny coverage for any portion of the 44 initial four weeks of continuous treatment, not to exceed twenty-eight 45 visits, for outpatient treatment on the basis that such treatment was 46 not medically necessary if such outpatient treatment was contrary to the 47 evidence-based and peer reviewed clinical review tool utilized by the 48 corporation which is designated by the office of [~~alcoholism and~~ 49 ~~substance abuse services~~] addiction services and supports. [~~A subscrib-~~ 50 er] An insured shall not have any financial obligation to the facility 51 for any treatment under this paragraph other than any copayment, coinsu- 52 rance, or deductible otherwise required under the contract. 53 § 11. Section 109 of the insurance law is amended by adding a new 54 subsection (e) to read as follows: 55 (e) In addition to any right of action granted to the superintendent 56 pursuant to this section, any person who has been injured by reason of a

S. 5300 9 1 violation of paragraphs thirty, thirty-one, thirty-one-a and thirty-five 2 of subsection (i) of section three thousand two hundred sixteen, para- 3 graphs five, six, seven and seven-a of subsection (l) of section three 4 thousand two hundred twenty-one, and subsections (g), (k), (l) or (l-1) 5 of section four thousand three hundred three of this chapter by an 6 insurer subject to article thirty-two or forty-three of this chapter may 7 bring an action in his or her own name to enjoin such unlawful act or 8 practice, an action to recover his or her actual damages or one thousand 9 dollars, whichever is greater, or both such actions. The court may, in 10 its discretion, award the prevailing plaintiff in such action an addi- 11 tional award not to exceed five thousand dollars, if the court finds the 12 defendant willfully violated the provisions of this section. The court 13 may award reasonable attorneys' fees to a prevailing plaintiff. 14 § 12. This act shall take effect January 1, 2025. 15 PART B 16 Section 1. Subparagraph (A) of paragraph 31-a of subsection (i) of 17 section 3216 of the insurance law, as added by chapter 748 of the laws 18 of 2019, is amended to read as follows: 19 (A) No policy that provides medical, major medical or similar compre- 20 hensive-type coverage and provides coverage for prescription drugs for 21 medication for the treatment of a substance use disorder shall require 22 prior authorization for an initial or renewal prescription for such 23 drugs for the detoxification or maintenance of a substance use disorder, 24 including all buprenorphine products, methadone [or], long acting 25 injectable naltrexone [~~for detoxification or maintenance treatment of a~~ 26 ~~substance use disorder~~] and medication for opioid overdose reversal 27 prescribed or dispensed to an individual covered under the policy, 28 except where otherwise prohibited by law. 29 § 2. Subparagraph (A) of paragraph 7-a of subsection (l) of section 30 3221 of the insurance law, as added by chapter 748 of the laws of 2019, 31 is amended to read as follows: 32 (A) No policy that provides medical, major medical or similar compre- 33 hensive-type small group coverage and provides coverage for prescription 34 drugs for medication for the treatment of a substance use disorder shall 35 require prior authorization for an initial or renewal prescription for 36 such drugs for the detoxification or maintenance of a substance use 37 disorder, including all buprenorphine products, methadone, long acting 38 injectable naltrexone, and medication for opioid overdose reversal 39 prescribed or dispensed to an individual covered under the policy, 40 except where otherwise prohibited by law. Every policy that provides 41 medical, major medical or similar comprehensive-type large group cover- 42 age shall provide coverage for prescription drugs for medication for the 43 treatment of a substance use disorder and shall provide immediate cover- 44 age for all buprenorphine products, methadone [or], long acting injecta- 45 ble naltrexone, and medication for opioid overdose reversal prescribed 46 or dispensed to an individual covered under the policy without prior 47 authorization for the detoxification or maintenance treatment of a 48 substance use disorder, except where otherwise prohibited by law. 49 § 3. Paragraph (A) of subsection (l-1) of section 4303 of the insur- 50 ance law, as added by chapter 748 of the laws of 2019, is amended to 51 read as follows: 52 (A) No contract that provides medical, major medical or similar 53 comprehensive-type individual or small group coverage and provides 54 coverage for prescription drugs for medication for the treatment of a

S. 5300 10 1 substance use disorder shall require prior authorization for an initial 2 or renewal prescription for such drugs for the detoxification or mainte- 3 nance of a substance use disorder, including all buprenorphine products, 4 methadone, long acting injectable naltrexone, and medication for opioid 5 overdose reversal prescribed or dispensed to an individual covered under 6 the contract, except where otherwise prohibited by law. Every contract 7 that provides medical, major medical, or similar comprehensive-type 8 large group coverage shall provide coverage for prescription drugs for 9 medication for the treatment of a substance use disorder and shall 10 provide immediate coverage for all buprenorphine products, methadone 11 [or], long acting injectable naltrexone, and medication for opioid over- 12 dose reversal prescribed or dispensed to an individual covered under the 13 contract without prior authorization for the detoxification or mainte- 14 nance treatment of a substance use disorder, except where otherwise 15 prohibited by law. 16 § 4. This act shall take effect immediately. 17 § 2. Severability clause. If any clause, sentence, paragraph, subdivi- 18 sion, section or part of this act shall be adjudged by any court of 19 competent jurisdiction to be invalid, such judgment shall not affect, 20 impair, or invalidate the remainder thereof, but shall be confined in 21 its operation to the clause, sentence, paragraph, subdivision, section 22 or part thereof directly involved in the controversy in which such judg- 23 ment shall have been rendered. It is hereby declared to be the intent of 24 the legislature that this act would have been enacted even if such 25 invalid provisions had not been included herein. 26 § 3. This act shall take effect immediately provided, however, that 27 the applicable effective date of Parts A through B of this act shall be 28 as specifically set forth in the last section of such Parts.

Relates to behavioral health parity

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