The Federal Parity Law 1

Technical Difficulties? Call (212) with technical problems during the webinar 2

Who Is Your Presenter? Karla Lopez, Esq. Staff Attorney Legal Action Center 3

Who Is the Legal Action Center? Non-profit law & policy organization Anti-discrimination & privacy work Substance Use Disorders HIV/AIDS Criminal Records Legal services, litigation, policy, technical assistance 4

Help from Legal Action Center Our website has many resources Call with questions about privacy or discrimination relating to HIV/AIDS, substance use disorders, or criminal records (212) Refer clients See next slide…. 5

Help from Legal Action Center We provide free legal services, including: Assistance with HIV testing & confidentiality Assistance with claims of discrimination based on: HIV status History of substance use disorder Criminal record: Rap sheet review & error correction Certificates of Relief & Good Conduct Job & housing discrimination 6

Today’s Training Explains the federal parity law Tells NYS service providers and advocates how they can take advantage of their rights, and the rights of their clients/patients, under the federal parity law We will take a 5 minute break halfway through today’s webinar 7

Get Credit for your Attendance! HAVE YOU REGISTERED? If you haven’t officially registered with the NYS Department of Health AIDS Institute, please do it now: If you need assistance, contact Vanessa Severino at 8

Today’s Handouts This PowerPoint Summary of NY AG Assurance of Discontinuance against MVP Health Care Summary of NY AG Assurance of Discontinuance against Emblem Health Letter from NYS DOH re: parity & Medicaid (10/2/2010) NYS Insurance Dept. Circular Letter No. 20 (2009) NYS Dept. of Financial Svc. Insurance Circular Letter No. 5 (2014) 9 Cont….

Today’s Handouts, cont…. Letter from Centers for Medicare & Medicaid Services to State Health Officials (11/4/2009) Letter from NYS DOH re: overdose prevention program (9/11/2014) Letter from NYS DOH re: PReP (7/24/2014) 2014 Opiate Legislation Package: Bill Summaries 10

Additional Resources SAMHSA’s parity web page: reform/parity?from=carousel&position=1&date= reform/parity?from=carousel&position=1&date= Parity Implementation Coalition Toolkit: ity%20Toolkit.pdf ity%20Toolkit.pdf Coalition for Whole Health:

Let’s find out! 12

POLL Do you work directly with clients or patients? Yes No 13

POLL If you do work directly with clients/patients, do you have clients/patients with substance use disorders? Yes No 14

POLL If you do work directly with clients/patients, do you have clients/patients with mental health issues? Yes No 15

POLL Have you noticed your patients/clients having more difficulty getting insurance coverage for substance use disorder or mental health treatment than for other kinds of medical and surgical care? Yes No Don’t know/can’t answer 16

POLL How familiar are you with the federal parity law? I’ve never heard of it I’ve heard of it but don’t know much about it I know a lot about it 17

Mental Health Parity & Addiction Equity Act of Overview 2. Who Must Comply 3. What Does It Require 18

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Federal Parity Law: Overview The Paul Wellstone & Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA), often referred to as the “federal parity law,” became federal law in October 2008, after 12 years of advocacy According to Congress, the purpose of the federal parity law is “to counter a history of discrimination and stigma against mental illness and substance- related disorders that has resulted in much less access to care.” 20

Federal Parity Law: Overview The federal parity law requires health insurance plans that cover mental health (MH) & substance use disorder (SUD) benefits to cover them equally (at “parity”) with other medical & surgical benefits 21

Federal Parity Law: Overview This means that it should no longer be more difficult for a patient to have her addiction treatment covered by her health insurance than to have her diabetes treatment covered. 22

Federal Parity Law: Overview Note on State Law: Many states have their own parity laws Today’s webinar will focus on the federal parity law, which applies to every state in the country New York State has a state parity law (“Timothy’s Law”), but it only covers mental health benefits, not substance use disorder benefits NYS also recently passed a package of laws in response to the opioid crisis—more info on those new laws later 23

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Federal Parity Law: Who Must Comply First, a few definitions…. Grandfathered plans are those that were in place on March 23, 2010 and have not made certain changes since then Non-grandfathered plans are those that were created after March 23, 2010, or those created before March 23, 2010 that have made certain changes since then Marketplace refers to the health insurance exchanges & marketplaces created by the Affordable Care Act (ACA) 25 Cont….

Federal Parity Law: Who Must Comply Definitions, cont…. Self-Insured plans are those where an employer pays directly for its employees' health care claims, rather than purchasing a plan from an insurance company; employers usually hire a third-party insurance company for administrative services such as enrollment and claims processing. Fully-Insured plans are those where an employer purchases a health plan on the commercial market and pays premiums to an insurance company to cover the cost of its employees’ health care claims. 26

Federal Parity Law: Who Must Comply? Most private and public health insurance plans must comply with the federal parity law, including: Large group health plans (i.e., most plans offered by private employers to their employees) Medicaid Managed Care plans Medicaid Alternative Benefit Plans (ABPs), including those provided to Medicaid expansion population Children’s Health Insurance Program (CHIP) Individual & small group plans sold on the marketplace Non-grandfathered individual & small group plans offered outside the marketplace Grandfathered individual plans offered outside the marketplace 27

Federal Parity Law: Who Must Comply? But, some health insurance plans do not have to comply with parity, including: Medicare Traditional (fee-for-service) Medicaid Plans that have successfully applied for a cost-increase exemption Self-insured plans offered by state & local government employers Grandfathered small group plans offered outside the marketplace Church sponsored plans Retiree-only plans TriCare 28

Federal Parity Law: Who Must Comply? Note on federal parity law & ACA: The Affordable Care Act (ACA) expanded the reach of the federal parity law by requiring additional types of health insurance plans to comply with parity Not every type of plan listed in the “who must comply” slide was covered by the 2008 parity law; some were added in 2010 by the ACA 29

Federal Parity Law: Who Must Comply? Note on federal parity law & ACA, cont…. The federal parity law does not require health insurance plans to cover MH & SUD benefits; it only imposes requirements on plans that do choose to provide such benefits. However, the Affordable Care Act (ACA) includes MH & SUD benefits in its list of Essential Health Benefits, meaning certain types of plans—namely plans sold to individuals & small groups on the marketplace and Medicaid plans for the “expansion population” under the ACA—must cover those benefits and cover them at parity 30

Federal Parity Law: Who Must Comply? Therefore, some plans must provide MH & SUD benefits to comply with the ACA, and they must provide the MH & SUD benefits equally with medical & surgical benefits because of the federal parity law. 31

Summary: Who Must Comply? If offer MH/SUD, must comply with parity Must offer MH/SUD, and comply with parity Not required to offer MH/SUD or comply with parity Large group plans Medicaid Managed Care plans Grandfathered individual plans offered outside marketplace/exchange Individual & small group plans sold on marketplace Non-grandfathered small group plans offered outside marketplace Non-grandfathered individual plans offered outside marketplace Medicaid ABPs CHIP (only required to offer MH) Medicare Grandfathered small group plans offered outside marketplace Plans w/cost increase exemption Church-sponsored Self-insured state & local govt employers Retiree-only Tri-Care 32

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Federal Parity Law: What Does It Require? The federal parity law (MHPAEA) says: the financial requirements and treatment limitations imposed by insurers on MH & SUD benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical & surgical benefits. In essence: MH/SUD benefits, if provided, must be provided equally with other medical/surgical benefits 34

Federal Parity Law: What Does It Require? What does all that mean? 35

Federal Parity Law: What Does It Require? First, what are financial requirements and treatment limitations? 36

Federal Parity Law: What Does It Require? What are financial requirements? Deductibles Co-payments Co-insurance Out-of-pocket maximums 37

Federal Parity Law: What Does It Require? What are treatment limitations? There are 2 kinds of treatment limitations: 1. Quantitative Treatment Limitations 2. Non-Quantitative Treatment Limitations (NQTLs) 38 Cont….

Federal Parity Law: What Does It Require? What are treatment limitations? Quantitative treatment limitations are those expressed numerically, such as Limits on the number of days or visits covered Limits on the frequency of treatment 39 Cont….

Federal Parity Law: What Does It Require? What are treatment limitations, cont… Non-Quantitative treatment limitations (NQTL) are not expressed numerically, but otherwise limit scope/duration—i.e., medical management tools: Medical necessity criteria Preauthorization requirements Prescription drug formulary design Fail-first or step therapy policies 40 Cont….

Federal Parity Law: What Does It Require? What are treatment limitations, cont… Non-Quantitative treatment limitations (NQTL), cont… Standards for provider admission to participate in- network Determination of usual, customary, reasonable amounts Exclusions based on failure to complete a course of treatment *Note: this is not an exhaustive list 41

CASE STUDY: Question Jay visits a psychologist once per week. His health insurance plan requires a $50 co-payment each time he visits his psychologist. Is this co-payment either a financial requirement or treatment limitation that is covered by the federal parity law? 42

CASE STUDY: Possible Answers Yes No 43

CASE STUDY: Correct Answer Yes, co-payments (like the $50 Jay must pay each time he sees his psychologist) are financial requirements, and therefore they must comply with the federal parity law. 44

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Federal Parity Law: What Does It Require? Now that we’ve discussed financial requirements & treatment limitations…. How do I know if they are more restrictive for MH/SUD benefits than for other medical/surgical benefits? (Remember: The federal parity law (MHPAEA) says the financial requirements and treatment limitations imposed on MH & SUD benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical & surgical benefits.) 46

Federal Parity Law: What Does It Require? The federal parity law’s regulations require all of a plan’s MH/SUD benefits and all of its medical/surgical benefits to be placed in one of 6 classifications, and provide a formula for comparing MH/SUD and medical/surgical benefits within each classification. 6 classifications: 1. Inpatient, in-network 2. Inpatient, out-of-network 3. Outpatient, in-network 4. Outpatient, out-of-network 5. Emergency care 6. Prescription drugs 47

Federal Parity Law: What Does It Require? 6 Classifications, cont… MH/SUD benefits in a given classification—such as inpatient, in-network—will be compared with other medical/surgical benefits in that same classification to determine whether the financial requirements & treatment limitations on the MH/SUD benefits are more restrictive. In other words, compare like with like. 48

CASE STUDY: Question Jay is wondering whether the $50 co-payment he is required to pay at his weekly visit to his psychologist complies with the parity law—that is, whether this financial requirement for an MH/SUD benefit is equal to similar medical/surgical benefits. Should Jay check to see whether the $50 co-payment for his psychologist visits is equal to: A. The co-payment he makes when he visits his primary care physician, or B. The co-payment he makes for a visit to the emergency room? 49

CASE STUDY: Possible Answers A. The co-payment he makes when he visits his primary care physician B. The co-payment he makes for a visit to the emergency room 50

CASE STUDY: Correct Answer A. The co-payment he makes when he visits his primary care physician Jay first needs to find out how his insurance plan classifies his psychologist visits, but they are most likely in the “outpatient” category. Therefore, Jay would need to compare his co-payment for the psychologist—an outpatient visit—to his co-payment for outpatient visits on the medical/surgical side, such as visits to a primary care physician. By contrast, a visit to the emergency room would presumably fall into the “emergency care” category, and therefore its co-payments should not be compared to co- payments in the “outpatient” category. 51

CASE STUDY: Correct Answer, cont. Remember: Compare like with like! 52 MH/SUDMedical/Surgical Inpatient Detoxification Inpatient Appendicitis Outpatient Psychologist visit Outpatient Primary care visit Emergency Care ER for overdose Emergency Care ER for broken leg Prescription Drugs Suboxone Prescription Drugs Blood pressure medication

Federal Parity Law: What Does It Require? 6 Classifications, cont… If a health plan offers MH/SUD benefits in any classification, MH/SUD benefits must be provided in every classification in which medical/surgical benefits are provided. 53

CASE STUDY: Question Gloria’s health insurance plan covers both outpatient and inpatient treatment for medical/surgical ailments. For example, it covers outpatient visits to her primary care doctor when she gets sick, and inpatient stays at the hospital when she has appendicitis and gives birth. Her plan also covers outpatient MH/SUD treatment— for example, outpatient addiction counseling. However, her plan will not cover inpatient detoxification for her addiction. Does Gloria’s plan meet the requirements of the federal parity law? 54

CASE STUDY: Possible Answers Yes No 55

CASE STUDY: Correct Answer No, it probably does not meet the requirements of the federal parity law (meaning it is probably illegal). Because Gloria’s health plan offers MH/SUD benefits in any classification (in this case, it offers them in the outpatient classification), it must offer them in every classification in which it offers medical/surgical benefits (in this case, both outpatient and inpatient). 56

Federal Parity Law: What Does It Require? Once all of the benefits have been put into one of the 6 classifications, how do you compare financial requirements & treatment limitations for MH/SUD vs. medical/surgical? (Remember: The federal parity law (MHPAEA) says the financial requirements and treatment limitations imposed on MH & SUD benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical & surgical benefits.) 57

Federal Parity Law: What Does It Require? For financial requirements and quantitative treatment limitations, cannot impose any on MH/SUD benefits that are separate from or more restrictive than the predominant ones applied to substantially all medical/surgical benefits in the same classification For non-quantitative treatment limitations (NQTLs), cannot impose any on MH/SUD that are not comparable to those used for medical/surgical, and cannot apply them more stringently to MH/SUD than medical/surgical 58

Federal Parity Law: What Does It Require? What does all that mean? 59

Federal Parity Law: What Does It Require? What do I need to know about “predominant” and “substantially all”? They are part of the formula for comparing MH/SUD benefits with medical/surgical benefits to determine whether they meet the requirements of the parity law. You don’t need to get bogged down in the details of the formula. If you see something that looks like a violation of the parity law, you can report it to the appropriate entity and they will do the analysis using the formula. We’ll talk more about that later. 60

Federal Parity Law: What Does It Require? Practices That Often Violate Federal Parity Law: Having 1 deductible for MH/SUD services and 1 for medical/surgical services that accumulate separately Limits on the # of days or visits for MH/SUD treatment, when there aren’t similar limits for medical/surgical Higher co-payments & co-insurance for MH/SUD than for medical/surgical (e.g., charging a “specialist” rate for MH/SUD outpatient visits, when a “specialist” rate isn’t charged for most medical/surgical outpatient visits) 61 Cont….

Federal Parity Law: What Does It Require? Practices That Often Violate Parity, cont… Requiring patient to “fail first” at MH/SUD outpatient treatment before approving residential or inpatient treatment (and not having similar policies for med/surgical) Requiring MH/SUD patients to get prior authorization at earlier stages of treatment or more frequently during treatment than medical/surgical patients 62 Cont….

Federal Parity Law: What Does It Require? Practices That Often Violate Parity, cont… Excluding intermediate levels of MH/SUD care, like residential treatment, from coverage, if the plan covers intermediate care (like skilled nursing) for medical/surgical Requiring MH/SUD patients to be treated in-state, but allowing medical/surgical patients to be treated out-of- state Putting yearly or lifetime limit on length of time patient can receive methadone, buprenorphine, or naltrexone 63

CASE STUDY: Question Claire’s physician has recommended inpatient treatment for her addiction. Claire’s insurance plan requires pre-authorization for inpatient addiction treatment. When Claire had inpatient treatment for salmonella, no pre-authorization was required. Does Claire’s plan comply with the federal parity law? 64

CASE STUDY: Possible Answers Yes No 65

CASE STUDY: Correct Answer No, the plan probably does not comply with parity. Pre-authorization requirements are a Non- Quantitative Treatment Limitation (“NQTL”). Remember, plans cannot impose any NQTLs on MH/SUD that are not comparable to those used for medical/surgical. Here, the MH/SUD NQTL (pre-authorization) is not comparable to the medical/surgical NQTL, in the inpatient classification, because pre-authorization is required for Claire’s inpatient addiction treatment but not for her inpatient salmonella treatment. 66

CASE STUDY: Question Phil enters the hospital for an inpatient detoxification from opioids that will last 7 days. His health plan requires pre-authorization for inpatient addiction treatment and also for inpatient medical/surgical treatment. When Phil’s physician applies for pre-authorization for his 7-day inpatient detox, the plan approves only one day at a time, requiring his physician to re-apply each day in order to complete his treatment. When Phil must spend a week in the hospital recovering from a surgical procedure, his insurance plan pre- authorizes the whole 7 days. Does Phil’s plan comply with the federal parity law? 67

CASE STUDY: Possible Answers Yes No 68

CASE STUDY: Correct Answer No, the plan probably does not comply with parity law. Remember, plans cannot apply any NQTLs (like pre- authorization requirements) more stringently to MH/SUD than medical/surgical. Here, plan is applying the MH/SUD NQTL (pre- authorization requirements) more stringently than the medical/surgical NQTL, because it will approve only one day of inpatient treatment at a time for Phil’s opioid detox, but will approve a full 7 days at once for his surgical recovery. 69

A Note on the Polls Remember that there is a formula to determine whether health insurance plans are complying with the federal parity law. Generally, those who enforce the federal parity law (mostly government regulators) are the ones who will apply the formula to decide for sure whether a plan has violated the law. Our polls don’t go into that level of detail, but are more to give you a general idea of things that probably violate the law so that you can recognize them and bring them to the attention of regulators & others. 70

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We are more than half-way finished! Next up: How to enforce rights under federal parity law 72

1. Transparency Requirements 2. Appeals 3. Government Enforcement 4. Lawsuit 73

Federal Parity Law: Enforcing Rights Steps to Take: 1. Request information from health insurance plan. 2. File internal appeal; if denied, file external appeal. 3. If appeal(s) denied, contact government agencies that enforce the law. 4. Additional option: Lawsuit. Note: You are not necessarily required to file appeals before contacting government agencies, but they will likely tell you to do so when you contact them before they will get involved. 74

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Enforcing Federal Parity Law: First, Request Information Transparency Requirements: Providers & patients have the right to certain information from health plans under the federal parity law…. 76 Cont….

Enforcing Federal Parity Law: First, Request Information Transparency Requirements, cont…. Most plans covered by the federal parity law must provide, if you request it: Written explanation of how non-quantitative treatment limitations (e.g., medical necessity criteria) are applied to their medical/surgical & MH/SUD benefits; Reason for denials of payment or reimbursement; Any additional evidence used to make benefit determinations during appeals. This info generally must be provided within 30 days of request, and free of charge. 77

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Enforcing Federal Parity Law: Second, File Appeals Internal & External Appeals: Ask the health plan how to file appeals. Look into expedited appeals if need be. Internal appeals are generally conducted by the health plan, while external appeals in NYS are conducted by the State Dept. of Financial Services: m m For both internal & external appeals: Pay careful attention to deadlines! 79

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Enforcing Federal Parity Law: Third, Contact Govt. Agencies If you think your patient’s health plan is violating the federal parity law, you can complain to the government agencies that are tasked with enforcing the law, or you can complain to the State Attorney General. 81 Cont….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies New York State Attorney General: NYS AG is proactively enforcing the federal parity law If you think a NYS health plan is violating parity, you can call the AG’s Health Care Bureau hotline: AG has settled 3 cases against NYS health plans for parity violations so far (Cigna, MVP Health Care, and Empire Health; MVP & Empire administered behavioral health benefits through ValueOptions) 82 Cont…

Enforcing Federal Parity Law: Third, Contact Govt. Agencies New York State Attorney General, cont… Examples of practices found by AG to violate parity: Not covering residential MH/SUD treatment Charging higher co-payments for outpatient mental health visits than for outpatient primary care visits More frequent denials of requests for pre-authorization & of claims for MH/SUD than for medical/surgical Requiring (unofficially) that patients “fail first” at outpatient MH/SUD treatment before approving inpatient 83 Cont….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies New York State Attorney General, cont… Examples of violations, cont…. Approving only a few days of MH/SUD treatment at a time Requiring MH/SUD providers to have treatment & discharge plans even for outpatient treatment Having a certain # of psychotherapy visits trigger special intensive utilization review Generic denial letters Not using OASAS Level of Care Criteria to determine medical necessity of SUD treatment 84

Enforcing Federal Parity Law: Third, Contact Govt. Agencies New York State Attorney General, cont… The AG can also enforce state laws, like the state parity law (which only applies to MH), and state laws regulating insurers 85

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Other Govt. Enforcement Options: The AG is just one option for enforcing the parity law The federal parity law itself gives enforcement authority to a variety of state and federal agencies Different agencies enforce federal parity law for different types of health plans Remember, it is advisable to appeal directly to the insurance plan before going to a government agency 86 Cont….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Medicaid Managed Care: For suspected parity violations by Medicaid managed care plans (remember, traditional fee-for-service Medicaid isn’t covered by the federal parity law): Primary enforcement responsibility: State Medicaid Director Jason Helgerson State Medicaid Director, Deputy Commissioner State of New York, Department of Health Empire State Plaza, Corning Tower, Room 1466 Albany, NY (518) 474‐ Cont….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Medicaid Managed Care, cont… If a State Medicaid Director is not “substantially enforcing” federal parity, you can complain instead to the U.S. Dept. of Health & Human Services about potential parity violations by Medicaid managed care plans: U.S. Dept. of Health & Human Services (877)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Individual & Small Group Plans: For suspected parity violations by individual plans or small group plans: Primary enforcement responsibility: State Insurance Commissioner Benjamin M. Lawsky Commissioner NYS Dept. of Financial Services One State Street New York, NY (212) Cont….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Individual & Small Group Plans, cont… If a State Insurance Commissioner is not “substantially enforcing” federal parity, you can complain to the U.S. Dept. of Health & Human Services instead about potential parity violations by individual & small group plans: U.S. Dept. of Health & Human Services (877)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Large Group Plans: For suspected parity violations by large group plans, enforcement authority is shared between several agencies, depending on whether the plan is self- insured or fully-insured. If you don’t know whether the plan is self- or fully- insured, you can call the plan and ask, or you can just go ahead and complain about the potential violation to one of the enforcement agencies (after your appeals), who will coordinate amongst themselves to determine who has authority. 91 Cont….

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Large Group Plans, cont… For suspected parity violations by large group plans: Remember: If you are unsure who to complain to, just pick an agency and they should coordinate amongst themselves 92 Self-Insured Large Group Plans Fully-Insured Large Group Plans U.S. Department of Labor (866) U.S. Department of Treasury (202) State Insurance Commissioner (see previous slide) U.S. Department of Health & Human Services (see previous slide)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies Non-Federal Government Plans (Self-Insured): For suspected parity violations by self-insured non- federal government plans (i.e., health insurance plans offered by state and local government employers): U.S. Dept. of Health & Human Services (877)

Enforcing Federal Parity Law: Third, Contact Govt. Agencies That’s a lot of information! Don’t worry too much about which government agency has enforcement authority over which type of plan; the federal government agencies have said they will help patients’ & providers’ complaints get to the appropriate agency. 94

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Enforcing Federal Parity Law: Additional Option—Lawsuit A patient can also enforce her rights under the federal parity law by filing a lawsuit in court against the insurance company To pursue this option, you and/or your patient should speak to an attorney 96

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Some Relevant New York State Laws 98

Other Laws to Know Court-Ordered Treatment—Insurance Coverage: NYS law requires Medicaid Managed Care plans in the state to cover court-ordered treatment (if the plan would otherwise cover that type of treatment) Example: Court orders defendant charged with sale of controlled substances into outpatient addiction treatment. If the person’s Medicaid plan provides coverage for outpatient addiction treatment generally, it would be required to cover that type of treatment when ordered by a court. This law is found at New York Social Services Law section 364-j(4)(r) 99

Other Laws to Know In June 2014, Gov. Cuomo signed a package of bills into law to combat NY’s opioid epidemic. The new laws require: All insurance policies that are regulated by the NYS Dept. of Financial Services and that provide hospital, major medical, or other similar comprehensive coverage must provide inpatient and outpatient services for the diagnosis & treatment of SUD, including detoxification & rehabilitation services. Financial requirements & treatment limitations of such coverage cannot be more restrictive than medical/surgical, and the coverage must comply with the federal parity law. 100 Cont….

Other Laws to Know New NY Laws to Combat Opioid Epidemic, cont… When NY insurers undertake utilization review for SUD treatment, they must employ “recognized evidence-based & peer reviewed clinical review criteria.” NY insurers must complete utilization review within 24 hours of receiving a request for inpatient SUD treatment, as long as the request is made 24 hours prior to discharge from inpatient; cannot deny coverage while UR is pending on basis of medical necessity or lack of prior authorization. 101 Cont….

Other Laws to Know New NY Laws to Combat Opioid Epidemic, cont… NY insurers must issue a decision within 24 hours of receiving an appeal of a denial of inpatient SUD treatment; if appeal is filed within 24 hours of the denial, insurer cannot deny treatment on the basis of medical necessity or lack of prior authorization while the appeal is pending. 102

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