“The trauma this pandemic has caused is incalculable and cannot be ignored, and it’s especially critical that those who struggle with mental health and substance abuse have the support they need,”
Commissioner of the
Under the new regulations, parity compliance programs must establish corporate governance for parity compliance, identify discrepancies in coverage of services for the treatment of mental health conditions and substance use disorder, and ensure appropriate identification and remediation of improper practices.
The regulations require insurers to designate an appropriately experienced individual who shall:
* Be responsible for assessing, monitoring, and managing parity compliance;
* Report directly to the insurer’s chief executive officer or other senior manager; and
* 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.
The compliance program must also include:
* Written policies and procedures that implement the compliance program, and describe how the insurer’s parity compliance is assessed, monitored, and managed;
* Methodologies for the identification and remediation of improper practices;
* A process for the actuarial certification of the analyses of the financial requirements and quantitative treatment limitations;
* Training and education for employees and directors;
* The methods by which employees and directors may report parity compliance issues; and
* A policy of non-intimidation and non-retaliation for good faith participation in the compliance program.
Practices that are prohibited and must be remediated within 60 days of discovery include:
* A utilization review policy that uses standards to determine the level of documentation required for mental health or substance use disorder benefits that are not comparable to or are more stringently applied than the standards used for medical or surgical benefits;
* 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;
* 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 more stringently applied than the methodology for developing and applying provider reimbursement rates for medical or surgical benefits; and
* Implementing claim edits or system configurations that provide for higher rates of approval through auto-adjudication of claims for inpatient medical or surgical benefits than for inpatient mental health or substance use disorder benefits.
The final regulations will go into effect on
A full copy of the DFS regulations (https://www.dfs.ny.gov/system/files/documents/2020/10/rf218_11nycrr230_text.pdf) can be found on the DFS website.