NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A9716
SPONSOR: Paulin TITLE OF BILL:
An act to amend the insurance law, in relation to providing insurance
coverage for chronic pain
SUMMARY OF PROVISIONS OF BILL:
Section 1 of the bill amends the Insurance Law, Section 3216 by insert-
ing a new paragraph 39; Section 2 of the bill amends the Insurance Law,
Section 3221 by inserting a new Paragraph 22; and Section 3 of the bill
amends the Insurance Law, Section 4303 by inserting a new subsection
(uu), such that respectively: a) every policy that provides medical,
major medical, or similar comprehensive-type coverage for pain manage-
ment services; b) every insurer issuing group or blanket policies in the
State of New York for pain management services; and c) every contract
issued by a hospital service corporation, health service corporation or
medical expense indemnity corporation that includes pain management
services shall provide coverage for non-opioid treatment of chronic
pain, including complementary and integrative care.
Treatment limitations and financial costs to patients may not be more
stringent than contained in substantially all medical benefits and any
opioid-based chronic pain treatment provided by the policy or contract.
Section 4 provides the effective date.
JUSTIFICATION:
This bill builds upon Section 3331 of the Public Health Law, Subdivision
9 ("Section 3331") which requires practitioners to consider, and discuss
nonopioid treatments with patients affected by pain, and if appropriate,
prescribe or provide a referral for such treatments prior to starting an
opioid.
Since Section 3331 lacks any payer requirements for coverage, most
patients are unable to afford and therefore access many of the treat-
ments recommend to their patients. The bill would require insurers to
provide coverage for non-opioid treatments, including complementary and
integrative treatments. Provision of adequate insurance coverage would
encourage primary care practitioners, other medical practitioners and
patients to seek out nonopioid treatments as a first line therapy, when
appropriate.
LEGISLATIVE HISTORY::
None
FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS::
A substantial portion of pain management practice involves invasive
treatments, such as surgery, and injections. Such treatments are expen-
sive, ineffective for many patients and frequently result in adverse
effects requiring additional medical attention. By contrast, the thera-
pies that this bill promotes are much less expensive and rarely produce
adverse effects. If this bill is enacted, it is expected that the out-
of-pocket cost burden to the state and local governments for employee
health insurance will be lower.
EFFECTIVE DATE:
The January 1 following enactment and applying to all policies and
contracts issued, renewed, modified, altered or amended on or after that
date.
STATE OF NEW YORK
________________________________________________________________________
9716
IN ASSEMBLY
April 3, 2024
___________
Introduced by M. of A. PAULIN -- read once and referred to the Committee
on Insurance
AN ACT to amend the insurance law, in relation to providing insurance
coverage for chronic pain
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subsection (i) of section 3216 of the insurance law is
2 amended by adding a new paragraph 39 to read as follows:
3 (39) (A) Every policy that provides medical, major medical, or similar
4 comprehensive-type coverage that provides coverage for pain management
5 services shall provide outpatient coverage for non-opioid treatment of
6 chronic pain including complementary and integrative treatments. Access
7 to non-opioid treatment shall be comparable to that of other covered
8 services. Coverage shall be comparable for services provided by licensed
9 professionals.
10 (B) Coverage under this subsection shall not apply financial require-
11 ments or treatment limitations to non-opioid treatment of chronic pain
12 that are more restrictive than either of the following: the predominant
13 financial requirements and treatment limitations applied to substantial-
14 ly all medical benefits covered by the contract; and the financial
15 requirements and treatment limitations applied to any opioid-based
16 treatment of chronic pain.
17 (C) For the purposes of this paragraph the following terms shall have
18 the following meanings:
19 (i) "financial requirement" means deductible, co-payments, co-insu-
20 rance and out-of-pocket expenses;
21 (ii) "predominant" means that a financial requirement or treatment
22 limitation is the most common or frequent of such type of limit or
23 requirement;
24 (iii) "treatment limitation" means limits on the frequency of treat-
25 ment, number of visits, days of coverage, or other similar limits on the
26 scope or duration of treatment and includes non-quantitative treatment
27 limitations such as: medical management standards limiting or excluding
28 benefits based on medical necessity, or based on whether the treatment
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD15062-01-4
A. 9716 2
1 is experimental or investigational; standards for provider admission to
2 participate in a network, including reimbursement rates; methods for
3 determining usual, customary and reasonable charges; exclusions based on
4 failure to complete a course of treatment; and restrictions based on
5 geographic location, facility type, provider specialty, and other crite-
6 ria that limit the scope or duration of benefits for services provided
7 under the contract; and
8 (iv) "Chronic pain" means pain that persists or recurs for more than
9 three months.
10 § 2. Subsection (l) of section 3221 of the insurance law is amended by
11 adding a new paragraph 22 to read as follows:
12 (22) (A) Every insurer delivering a group or blanket policy or issuing
13 a group or blanket policy for delivery in this state that provides
14 coverage for pain management services shall provide outpatient coverage
15 for non-opioid treatment of chronic pain including complementary and
16 integrative treatments. Access to non-opioid treatment shall be compara-
17 ble to that of other covered services. Coverage shall be comparable for
18 services provided by licensed professionals.
19 (B) Coverage under this subsection shall not apply financial require-
20 ments or treatment limitations to non-opioid treatment of chronic pain
21 that are more restrictive than either of the following: the predominant
22 financial requirements and treatment limitations applied to substantial-
23 ly all medical benefits covered by the contract; and the financial
24 requirements and treatment limitations applied to any opioid-based
25 treatment of chronic pain.
26 (C) For the purposes of this paragraph the following terms shall have
27 the following meanings:
28 (i) "financial requirement" means deductible, co-payments, co-insu-
29 rance and out-of-pocket expenses;
30 (ii) "predominant" means that a financial requirement or treatment
31 limitation is the most common or frequent of such type of limit or
32 requirement;
33 (iii) "treatment limitation" means limits on the frequency of treat-
34 ment, number of visits, days of coverage, or other similar limits on the
35 scope or duration of treatment and includes non-quantitative treatment
36 limitations such as: medical management standards limiting or excluding
37 benefits based on medical necessity, or based on whether the treatment
38 is experimental or investigational; standards for provider admission to
39 participate in a network, including reimbursement rates; methods for
40 determining usual, customary and reasonable charges; exclusions based on
41 failure to complete a course of treatment; and restrictions based on
42 geographic location, facility type, provider specialty, and other crite-
43 ria that limit the scope or duration of benefits for services provided
44 under the contract; and
45 (iv) "chronic pain" means pain that persists or recurs for more than
46 three months.
47 § 3. Section 4303 of the insurance law is amended by adding a new
48 subsection (vv) to read as follows:
49 (vv) (1) Every contract issued by a hospital service corporation,
50 health service corporation or medical expense indemnity corporation that
51 includes coverage for pain management services shall provide outpatient
52 coverage for non-opioid treatment of chronic pain including complementa-
53 ry and integrative treatments. Access to non-opioid treatment shall be
54 comparable to that of other covered services. Coverage shall be compara-
55 ble for services provided by licensed professionals.
A. 9716 3
1 (2) Coverage under this subsection shall not apply financial require-
2 ments or treatment limitations to non-opioid treatment of chronic pain
3 that are more restrictive than either of the following: the predominant
4 financial requirements and treatment limitations applied to substantial-
5 ly all medical benefits covered by the contract; and the financial
6 requirements and treatment limitations applied to any opioid-based
7 treatment of chronic pain.
8 (3) For the purposes of this subsection the following terms shall have
9 the following meanings:
10 (A) "financial requirement" means deductible, co-payments, co-insu-
11 rance and out-of-pocket expenses;
12 (B) "predominant" means that a financial requirement or treatment
13 limitation is the most common or frequent of such type of limit or
14 requirement;
15 (C) "treatment limitation" means limits on the frequency of treatment,
16 number of visits, days of coverage, or other similar limits on the scope
17 or duration of treatment and includes non-quantitative treatment limita-
18 tions such as: medical management standards limiting or excluding bene-
19 fits based on medical necessity, or based on whether the treatment is
20 experimental or investigational; standards for provider admission to
21 participate in a network, including reimbursement rates; methods for
22 determining usual, customary and reasonable charges; exclusions based on
23 failure to complete a course of treatment; and restrictions based on
24 geographic location, facility type, provider specialty, and other crite-
25 ria that limit the scope or duration of benefits for services provided
26 under the contract; and
27 (D) "chronic pain" means pain that persists or recurs for more than
28 three months.
29 § 4. This act shall take effect the first day of January next succeed-
30 ing the day on which it shall have become a law and shall apply to all
31 policies and contracts issued, renewed, modified, altered, or amended on
32 or after such date.
