New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter IX - Unfair Trade Practices
Part 230 - Mental Health and Substance Use Disorder Parity Compliance Program
Section 230.3 - Mental health and substance use disorder parity compliance program

(i) be responsible for assessing, monitoring, and managing parity compliance;

(ii) report directly to the insurer's chief executive officer or other senior manager; and

(iii) report no less than annually to the insurer's board of directors or other governing body, or the appropriate committee thereof, on the activities of the compliance program;

(i) a system for assigning each benefit to the defined benefit classifications as required by MHPAEA;

(ii) methodologies for the identification and testing of all financial requirements and quantitative treatment limitations; and

(iii) methodologies for the identification and testing, including a comparative analysis, of all non-quantitative treatment limitations that are imposed on mental health or substance use disorder benefits;

(i) review of a statistically valid sample of preauthorization, concurrent, and retrospective review denials for mental health and substance use disorder benefits to ensure such determinations were consistent with the clinical review criteria approved by the commissioner of mental health or designated by the commissioner of addiction services and supports, in consultation with the superintendent and commissioner of health, and that such criteria have been applied comparably to and no more stringently than criteria applied to medical or surgical benefits;

(ii) review of the comparability of coverage within each benefit classification for mental health and substance use disorder benefits to ensure that coverage for a comparable continuum of services is available for mental health and substance use disorder benefits as is available for medical or surgical benefits, including residential and outpatient rehabilitation services;

(iii) review of the percentage of services provided by out-of-network providers for mental health and substance use disorder benefits where no in-network provider was available compared to the percentage of services provided by out-of-network providers for medical and surgical benefits where no in-network provider was available, to ensure that the processes and strategies for the recruitment and retention of mental health or substance use disorder providers are effective in reducing disparities in out-of-network use and to ensure there is an adequate network of mental health and substance use disorder providers to provide services on an in-network basis;

(iv) review of provider credentialing policies and procedures to ensure that the documentation and qualifications required for credentialing mental health and substance use disorder providers are comparable to and applied no more stringently than the documentation and qualifications required for credentialing medical or surgical providers and to ensure there is an adequate network of mental health and substance use disorder providers to provide services on an in-network basis;

(v) review of the average length of time to negotiate provider agreements and negotiated reimbursement rates with network providers and methods for the determination of usual, customary and reasonable charges, to ensure that reimbursement rates for mental health and substance use disorder benefits are established using standards that are comparable to and applied no more stringently than the standards used for medical or surgical benefits and to ensure there is an adequate network of mental health and substance use disorder providers to provide services on an in-network basis;

(vi) review of insurer policies for the automatic or systematic lowering, non-payment or application of a particular coding for mental health and substance use disorder benefits to ensure that they are comparable to and applied no more than stringently than insurer policies for the automatic or systematic lowering, non-payment or application of a particular coding for medical or surgical benefits;

(vii) review of all mental health and substance use disorder medications subject to nonquantitative treatment limitations, including step-therapy protocols or other preauthorization requirements, to ensure that the factors, such as cost and latency periods, processes, strategies, and evidentiary standards the insurer relied upon to determine whether to apply the nonquantitative treatment limitation were comparable to and applied no more stringently than the factors, processes, strategies, and evidentiary standards the insurer relied upon to determine whether to apply nonquantitative treatment limitations, including step therapy or other preauthorization requirements, to medications to treat medical or surgical conditions;

(viii) review of any fail-first requirements applicable to mental health or substance use disorder benefits to ensure that they are comparable to and applied no more stringently than any fail-first requirements applicable to medical or surgical benefits; and

(ix) review of any restrictions based on geographic location, facility type, provider specialty, or other criteria applicable to mental health or substance use disorder benefits to ensure that any such restriction is comparable to and applied no more stringently than any restriction applicable to medical or surgical benefits;

(i) implementing a utilization review policy that uses standards to determine the level of documentation required for utilization review of mental health or substance use disorder benefits that are not comparable to or are applied more stringently than the standards used to determine the level of documentation required for the utilization review of medical or surgical conditions, including the submission of medical records, treatment plans, or evidence of patient involvement or motivation in care or patient response to treatment;

(ii) requiring preauthorization, concurrent, or retrospective utilization review for a higher percentage of mental health or substance use disorder benefits in the absence of defined clinical or quality triggers, as compared to medical or surgical benefits;

(iii) implementing a methodology for developing and applying provider reimbursement rates for mental health or substance use disorder benefits that is not comparable to or is applied more stringently than the methodology for developing and applying provider reimbursement rates for medical or surgical benefits; and

(iv) implementing claim edits or system configurations that provide for higher rates of approval through auto-adjudication for claims for inpatient medical or surgical benefits than for inpatient mental health or substance use disorder benefits.

(i) set forth the insurer's NAIC number, if applicable;

(ii) identify the specific filing or submission for which the insurer is applying for the exemption;

(iii) specify whether the insurer is making the request for an exemption based upon undue hardship, impracticability, or good cause, and set forth a detailed explanation as to the reason that the superintendent should approve the request; and

(iv) specify whether the request for an exemption extends to future filings or submissions, in addition to the specific filing or submission identified in paragraph (2) of this subdivision.