A 7038: Requires rates paid for rehabilitation and opioid treatment be pursuant to certain fee schedules published by the office of addiction services and supports.

  
  STATE OF NEW YORK ________________________________________________________________________ 7038 2025-2026 Regular Sessions  IN ASSEMBLY March 18, 2025 ___________ Introduced by M. of A. WEPRIN -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, in relation to requiring rates paid for rehabilitation and opioid treatment be pursuant to certain fee schedules published by the office of addiction services and supports The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subparagraph (J) of paragraph 31 of subsection (i) of 2 section 3216 of the insurance law, as added by section 1 of part AA of 3 chapter 57 of the laws of 2024, is amended to read as follows: 4 (J) This subparagraph shall apply to facilities in this state that are 5 licensed, certified, or otherwise authorized by the office of addiction 6 services and supports for the provision of outpatient, intensive outpa- 7 tient, outpatient rehabilitation and opioid treatment that are partic- 8 ipating in the insurer's provider network. Reimbursement for covered 9 outpatient treatment provided by such facilities shall be at rates nego- 10 tiated between the insurer and the participating facility, provided that 11 such rates are not less than the rates that would be paid for such 12 treatment pursuant to the medical assistance program under title eleven 13 of article five of the social services law. For the purposes of this 14 subparagraph, the rates that would be paid for such treatment pursuant 15 to the medical assistance program under title eleven of article five of 16 the social services law shall be set forth in a published fee schedule 17 setting forth the specific fee for each individual service covered by 18 this subparagraph by the office of addiction services and supports and 19 shall be the rates with an effective date of April first of the preced- 20 ing year, which shall be established prior to October first of the 21 preceding calendar year. Prior to the submission of premium rate filings 22 and applications, the superintendent shall provide insurers with guid- 23 ance on factors to consider in calculating the impact of rate changes 24 for the purposes of submitting premium rate filings and applications to EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD11143-01-5 
 A. 7038 2 1 the superintendent for the subsequent policy year. To the extent that 2 the rates with an effective date of April first differ from the esti- 3 mated rates incorporated in premium rate filings and applications, 4 insurers may account for such differences in future premium rate filings 5 and applications submitted to the superintendent for approval. 6 § 2. Subparagraph (K) of paragraph 35 of subsection (i) of section 7 3216 of the insurance law, as added by section 2 of part AA of chapter 8 57 of the laws of 2024, is amended to read as follows: 9 (K) This subparagraph shall apply to outpatient treatment provided in 10 a facility issued an operating certificate by the commissioner of mental 11 health pursuant to the provisions of article thirty-one of the mental 12 hygiene law, or in a facility operated by the office of mental health, 13 or in a crisis stabilization center licensed pursuant to section 36.01 14 of the mental hygiene law, that is participating in the insurer's 15 provider network. Reimbursement for covered outpatient treatment 16 provided by such a facility shall be at rates negotiated between the 17 insurer and the participating facility, provided that such rates are not 18 less than the rates that would be paid for such treatment pursuant to 19 the medical assistance program under title eleven of article five of the 20 social services law. For the purposes of this subparagraph, the rates 21 that would be paid for such treatment pursuant to the medical assistance 22 program under title eleven of article five of the social services law 23 shall be set forth in a published fee schedule setting forth the specif- 24 ic fee for each individual service covered by this subparagraph by the 25 office of mental health and shall be the rates with an effective date of 26 April first of the preceding year, which shall be established prior to 27 October first of the preceding calendar year. Prior to the submission of 28 premium rate filings and applications, the superintendent shall provide 29 insurers with guidance on factors to consider in calculating the impact 30 of rate changes for the purposes of submitting premium rate filings and 31 applications to the superintendent for the subsequent policy year. To 32 the extent that the rates with an effective date of April first differ 33 from the estimated rates incorporated in premium rate filings and appli- 34 cations, insurers may account for such differences in future premium 35 rate filings and applications submitted to the superintendent for 36 approval. 37 § 3. Subparagraph (K) of paragraph 5 of subsection (l) of section 3221 38 of the insurance law, as added by section 3 of part AA of chapter 57 of 39 the laws of 2024, is amended to read as follows: 40 (K) This subparagraph shall apply to outpatient treatment provided in 41 a facility issued an operating certificate by the commissioner of mental 42 health pursuant to the provisions of article thirty-one of the mental 43 hygiene law, or in a facility operated by the office of mental health, 44 or in a crisis stabilization center licensed pursuant to section 36.01 45 of the mental hygiene law, that is participating in the insurer's 46 provider network. Reimbursement for covered outpatient treatment 47 provided by such a facility shall be at rates negotiated between the 48 insurer and the participating facility, provided that such rates are not 49 less than the rates that would be paid for such treatment pursuant to 50 the medical assistance program under title eleven of article five of the 51 social services law. For the purposes of this subparagraph, the rates 52 that would be paid for such treatment pursuant to the medical assistance 53 program under title eleven of article five of the social services law 54 shall be set forth in a published fee schedule setting forth the specif- 55 ic fee for each individual service covered by this subparagraph by the 56 office of mental health and shall be the rates with an effective date of 
 A. 7038 3 1 April first of the preceding year, which shall be established prior to 2 October first of the preceding calendar year. Prior to the submission of 3 premium rate filings and applications, the superintendent shall provide 4 insurers with guidance on factors to consider in calculating the impact 5 of rate changes for the purposes of submitting premium rate filings and 6 applications to the superintendent for the subsequent policy year. To 7 the extent that the rates with an effective date of April first differ 8 from the estimated rates incorporated in premium rate filings and appli- 9 cations, insurers may account for such differences in future premium 10 rate filings and applications submitted to the superintendent for 11 approval. 12 § 4. Subparagraph (J) of paragraph 7 of subsection (l) of section 3221 13 of the insurance law, as added by section 4 of part AA of chapter 57 of 14 the laws of 2024, is amended to read as follows: 15 (J) This subparagraph shall apply to facilities in this state that are 16 licensed, certified, or otherwise authorized by the office of addiction 17 services and supports for the provision of outpatient, intensive outpa- 18 tient, outpatient rehabilitation and opioid treatment that are partic- 19 ipating in the insurer's provider network. Reimbursement for covered 20 outpatient treatment provided by such facilities shall be at rates nego- 21 tiated between the insurer and the participating facility, provided that 22 such rates are not less than the rates that would be paid for such 23 treatment pursuant to the medical assistance program under title eleven 24 of article five of the social services law. For the purposes of this 25 subparagraph, the rates that would be paid for such treatment pursuant 26 to the medical assistance program under title eleven of article five of 27 the social services law shall be set forth in a published fee schedule 28 setting forth the specific fee for each individual service covered by 29 this subparagraph by the office of addiction services and supports and 30 shall be the rates with an effective date of April first of the preced- 31 ing year, which shall be established prior to October first of the 32 preceding calendar year. Prior to the submission of premium rate filings 33 and applications, the superintendent shall provide insurers with guid- 34 ance on factors to consider in calculating the impact of rate changes 35 for the purposes of submitting premium rate filings and applications to 36 the superintendent for the subsequent policy year. To the extent that 37 the rates with an effective date of April first differ from the esti- 38 mated rates incorporated in premium rate filings and applications, 39 insurers may account for such differences in future premium rate filings 40 and applications submitted to the superintendent for approval. 41 § 5. Paragraph 12 of subsection (g) of section 4303 of the insurance 42 law, as added by section 5 of part AA of chapter 57 of the laws of 2024, 43 is amended to read as follows: 44 (12) This paragraph shall apply to outpatient treatment provided in a 45 facility issued an operating certificate by the commissioner of mental 46 health pursuant to the provisions of article thirty-one of the mental 47 hygiene law, or in a facility operated by the office of mental health, 48 or in a crisis stabilization center licensed pursuant to section 36.01 49 of the mental hygiene law, that is participating in the corporation's 50 provider network. Reimbursement for covered outpatient treatment 51 provided by such facility shall be at rates negotiated between the 52 corporation and the participating facility, provided that such rates are 53 not less than the rates that would be paid for such treatment pursuant 54 to the medical assistance program under title eleven of article five of 55 the social services law. For the purposes of this paragraph, the rates 56 that would be paid for such treatment pursuant to the medical assistance 
 A. 7038 4 1 program under title eleven of article five of the social services law 2 shall be set forth in a published fee schedule setting forth the specif- 3 ic fee for each individual service covered by this paragraph by the 4 office of mental health and shall be the rates with an effective date of 5 April first of the preceding year, which shall be established prior to 6 October first of the preceding calendar year. Prior to the submission of 7 premium rate filings and applications, the superintendent shall provide 8 corporations with guidance on factors to consider in calculating the 9 impact of rate changes for the purposes of submitting premium rate 10 filings and applications to the superintendent for the subsequent policy 11 year. To the extent that the rates with an effective date of April first 12 differ from the estimated rates incorporated in premium rate filings and 13 applications, corporations may account for such differences in future 14 premium rate filings and applications submitted to the superintendent 15 for approval. 16 § 6. Paragraph 10 of subsection (l) of section 4303 of the insurance 17 law, as added by section 6 of part AA of chapter 57 of the laws of 2024, 18 is amended to read as follows: 19 (10) This paragraph shall apply to facilities in this state that are 20 licensed, certified, or otherwise authorized by the office of addiction 21 services and supports for the provision of outpatient, intensive outpa- 22 tient, outpatient rehabilitation and opioid treatment that are partic- 23 ipating in the corporation's provider network. Reimbursement for covered 24 outpatient treatment provided by such facilities shall be at rates nego- 25 tiated between the corporation and the participating facility, provided 26 that such rates are not less than the rates that would be paid for such 27 treatment pursuant to the medical assistance program under title eleven 28 of article five of the social services law. For the purposes of this 29 paragraph, the rates that would be paid for such treatment pursuant to 30 the medical assistance program under title eleven of article five of the 31 social services law shall be set forth in a published fee schedule 32 setting forth the specific fee for each individual service covered by 33 this paragraph by the office of addiction services and supports and 34 shall be the rates with an effective date of April first of the preced- 35 ing year, which shall be established prior to October first of the 36 preceding calendar year. Prior to the submission of premium rate filings 37 and applications, the superintendent shall provide corporations with 38 guidance on factors to consider in calculating the impact of rate chang- 39 es for the purposes of submitting premium rate filings and applications 40 to the superintendent for the subsequent policy year. To the extent that 41 the rates with an effective date of April first differ from the esti- 42 mated rates incorporated in premium rate filings and applications, 43 corporations may account for such differences in future premium rate 44 filings and applications submitted to the superintendent for approval. 45 § 7. This act shall take effect immediately and shall apply to all 46 policies and contracts issued, renewed, modified, altered, or amended on 47 or after such date.