2019 New York Laws
ISC - Insurance
Article 3 - Administrative and Procedural Provisions
343 - Mental Health and Substance Use Disorder Parity Report.

§  343.  Mental  health  and substance use disorder parity report. (a)
Beginning  July  first,  two  thousand  nineteen  and  every  two  years
thereafter,  each  insurer  providing  managed care products, individual
comprehensive  accident  and  health  insurance  or  group  or   blanket
comprehensive  accident and health insurance, each corporation organized
pursuant to article forty-three of this chapter providing  comprehensive
health insurance and each entity licensed pursuant to article forty-four
of  the  public  health law providing comprehensive health service plans
shall submit to the superintendent, in a form and manner  prescribed  by
the  superintendent,  a  report  detailing  the entity's compliance with
federal and state mental health and substance use disorder  parity  laws
based  on  the  entity's record during the preceding two calendar years.
The superintendent shall publish  on  the  department's  website  on  or
before  October  first,  two  thousand  nineteen,  and  every  two years
thereafter, the reports submitted pursuant to this section.
  (b) Each person required to submit a report under this  section  shall
include in the report the following information:
  (1)  Rates  of  utilization review for mental health and substance use
disorder claims as compared to medical and  surgical  claims,  including
rates of approval and denial, categorized by benefits provided under the
following     classifications:     inpatient    in-network,    inpatient
out-of-network,  outpatient   in-network,   outpatient   out-of-network,
emergency care, and prescription drugs;
  (2)  The  number  of  prior  or  concurrent authorization requests for
mental health services and for substance use disorder services  and  the
number  of  denials for such requests, compared with the number of prior
or concurrent authorization requests for medical and  surgical  services
and  the  number  of  denials for such requests, categorized by the same
classifications identified in paragraph one of this subsection;
  (3) The rates of appeals  of  adverse  determinations,  including  the
rates of adverse determinations upheld and overturned, for mental health
claims  and  substance  use  disorder  claims compared with the rates of
appeals of  adverse  determinations,  including  the  rates  of  adverse
determinations upheld and overturned, for medical and surgical claims;
  (4)  The  percentage  of  claims  paid  for  in-network  mental health
services and for substance  use  disorder  services  compared  with  the
percentage  of  claims paid for in-network medical and surgical services
and the percentage of  claims  paid  for  out-of-network  mental  health
services   and   substance  use  disorder  services  compared  with  the
percentage of  claims  paid  for  out-of-network  medical  and  surgical
services;
  (5)  The  number  of  behavioral  health  advocates,  pursuant  to  an
agreement with the office of the  attorney  general  if  applicable,  or
staff  available to assist policyholders with mental health benefits and
substance use disorder benefits;
  (6) A comparison of the cost sharing requirements  including  but  not
limited   to  co-pays  and  coinsurance,  and  the  benefit  limitations
including limitations on the scope and duration of coverage, for medical
and surgical services, and mental  health  services  and  substance  use
disorder services for coverage in the individual, small group, and large
group   markets,   provided   that  the  comparison  captures  at  least
seventy-five percent of a company's enrollees in each market;
  (7) The number by type of providers licensed to practice in this state
that provide services for the treatment and diagnosis of  substance  use
disorder  who  are  in-network,  and  the  number  by  type of providers
licensed to practice  in  this  state  that  provide  services  for  the
diagnosis  and  treatment  of mental, nervous or emotional disorders and
ailments, however defined in a company's policy, who are in-network;
  (8) The percentage of providers of  services  for  the  treatment  and
diagnosis   of   substance   use  disorder  who  remained  participating
providers, and the percentage of providers of services for the diagnosis
and treatment of mental, nervous or emotional  disorders  and  ailments,
however  defined  in  a  company's  policy,  who  remained participating
providers; and
  (9) Any other data, information, or metric  the  superintendent  deems
necessary  or  useful  to  measure  compliance  with  mental  health and
substance  use  disorder  parity  including,  but  not  limited  to   an
evaluation  and  assessment  of:  (i)  the  adequacy  of  the  company's
in-network mental health services and substance  use  disorder  provider
panels  pursuant  to  provisions  of the insurance law and public health
law;  and  (ii)  the  company's   reimbursement   for   in-network   and
out-of-network   mental  health  services  and  substance  use  disorder
services  as  compared  to  the   reimbursement   for   in-network   and
out-of-network medical and surgical services.