§ 343 — Mental health and substance use disorder parity report

§ 343. Mental health and substance use disorder parity report. (a)\nBeginning July first, two thousand nineteen and every two years\nthereafter, each insurer providing managed care products, individual\ncomprehensive accident and health insurance or group or blanket\ncomprehensive accident and health insurance, each corporation organized\npursuant to article forty-three of this chapter providing comprehensive\nhealth insurance and each entity licensed pursuant to article forty-four\nof the public health law providing comprehensive health service plans\nshall submit to the superintendent, in a form and manner prescribed by\nthe superintendent, a report detailing the entity's compliance with\nfederal and state mental health and substance use disorder parity laws\nbased on the entity's record during the preceding two calendar years.\nThe superintendent shall publish on the department's website on or\nbefore October first, two thousand nineteen, and every two years\nthereafter, the reports submitted pursuant to this section.\n (b) Each person required to submit a report under this section shall\ninclude in the report the following information:\n (1) Rates of utilization review for mental health and substance use\ndisorder claims as compared to medical and surgical claims, including\nrates of approval and denial, categorized by benefits provided under the\nfollowing classifications: inpatient in-network, inpatient\nout-of-network, outpatient in-network, outpatient out-of-network,\nemergency care, and prescription drugs;\n (2) The number of prior or concurrent authorization requests for\nmental health services and for substance use disorder services and the\nnumber of denials for such requests, compared with the number of prior\nor concurrent authorization requests for medical and surgical services\nand the number of denials for such requests, categorized by the same\nclassifications identified in paragraph one of this subsection;\n (3) The rates of appeals of adverse determinations, including the\nrates of adverse determinations upheld and overturned, for mental health\nclaims and substance use disorder claims compared with the rates of\nappeals of adverse determinations, including the rates of adverse\ndeterminations upheld and overturned, for medical and surgical claims;\n (4) The percentage of claims paid for in-network mental health\nservices and for substance use disorder services compared with the\npercentage of claims paid for in-network medical and surgical services\nand the percentage of claims paid for out-of-network mental health\nservices and substance use disorder services compared with the\npercentage of claims paid for out-of-network medical and surgical\nservices;\n (5) The number of behavioral health advocates, pursuant to an\nagreement with the office of the attorney general if applicable, or\nstaff available to assist policyholders with mental health benefits and\nsubstance use disorder benefits;\n (6) A comparison of the cost sharing requirements including but not\nlimited to co-pays and coinsurance, and the benefit limitations\nincluding limitations on the scope and duration of coverage, for medical\nand surgical services, and mental health services and substance use\ndisorder services for coverage in the individual, small group, and large\ngroup markets, provided that the comparison captures at least\nseventy-five percent of a company's enrollees in each market;\n (7) The number by type of providers licensed to practice in this state\nthat provide services for the treatment and diagnosis of substance use\ndisorder who are in-network, and the number by type of providers\nlicensed to practice in this state that provide services for the\ndiagnosis and treatment of mental, nervous or emotional disorders and\nailments, however defined in a company's policy, who are in-network;\n (8) The percentage of providers of services for the treatment and\ndiagnosis of substance use disorder who remained participating\nproviders, and the percentage of providers of services for the diagnosis\nand treatment of mental, nervous or emotional disorders and ailments,\nhowever defined in a company's policy, who remained participating\nproviders; and\n (9) Any other data, information, or metric the superintendent deems\nnecessary or useful to measure compliance with mental health and\nsubstance use disorder parity including, but not limited to an\nevaluation and assessment of: (i) the adequacy of the company's\nin-network mental health services and substance use disorder provider\npanels pursuant to provisions of the insurance law and public health\nlaw; and (ii) the company's reimbursement for in-network and\nout-of-network mental health services and substance use disorder\nservices as compared to the reimbursement for in-network and\nout-of-network medical and surgical services.\n