On April 12, 2018, Gov. Cuomo signed a budget bill that also included several changes to the New York Health Benefit Mandates. Generally, S 7507 enacts into law major components of legislation necessary to implement the state health and mental hygiene budget for the 2018-2019 fiscal year, but also includes the following health benefit mandates:
Outpatient Coverage for Diagnosis and Treatment of Substance Use Disorders
Effective April 12, 2018, and until June 30, 2024, New York-based facilities certified by the New York Office of Alcoholism and Substance Abuse Services that participate in insurers’ provider networks and provide outpatient, intensive outpatient, outpatient rehabilitation and opioid treatment can’t be subject to: (i) preauthorization or (ii) a concurrent review for the first two weeks of continuous treatment, not to exceed 14 visits, so long as the facilities notify insurers within 48 hours after plan participants are admitted about the start of treatment and the initial treatment plan.
Facilities must perform clinical assessments of plan participants at each visit, including periodic consultations with insurers to ensure that the facilities are using the insurers’ evidence-based and peer-reviewed clinical tool, as designated by the New York Office of Alcoholism and Substance Abuse Services and appropriate to the participant’s age, to ensure that outpatient treatment is medically necessary.
Utilization reviews can include all services provided during outpatient treatment, including all services provided during the first two weeks of continuous treatment, not to exceed 14 visits, of such outpatient treatment. However, during the initial two weeks, insurers can only deny coverage for outpatient treatment on the basis that such treatment isn’t medically necessary if the treatment is contrary to the clinical review tool used by the insurer. Facilities providing such treatments can only charge participants for copayments, coinsurance or deductibles otherwise required under plans.
NY Passes Law to Require Hospitals to Provide Pasteurized Donor Human Milk
Effective April 12, 2018, and until June 30, 2024, plans that provide hospital, surgical or medical coverage must provide coverage for pasteurized donor human milk, including fortifiers, as medically indicated for inpatient use by certain infants:
- For which licensed medical practitioners issue orders deeming the infants medically or physically unable to receive maternal breast milk or participate in breastfeeding, or
- Whose mothers are medically or physically unable to produce maternal breast milk at all or in sufficient quantities or participate in breastfeeding despite optimal lactation support.
Such infants must have:
- Documented birth weights of less than 1,500 grams, or
- Congenital or acquired conditions that place them at a high risk for developing necrotizing enterocolitis.